Spontaneous deep vein thrombosis in the upper extremity of a 45-year-old woman

Abstract

A 45-year-old woman presented to her family doctor following a three-day history of acute-onset, progressive swelling and sensation of heaviness in her left upper extremity. In addition, she described pleuritic chest pain and dyspnea on exertion. Five days before presentation, she had been lifting heavy furniture and boxes and had performed her regular exercise routine that involved lifting 10-and 15-pound weights overhead. She had no history of thrombosis and no family history of clotting disorders. Her medical history included Hashimoto thyroiditis and remote iron deficiency anemia secondary to menorrhagia. Cancer screening had yielded normal results on a Papanicolaou test and a colonoscopy performed three years earlier. She had no recent immobilization, surgery or long-distance travel and was not taking supplemental estrogen. The patient was referred to the emergency department for evaluation of suspected deep vein thrombosis (DVT) in her left upper extremity and pulmonary embolus.In the emergency department, she had a regular heart rate of 96 beats/min and an oxygen saturation of 95% on room air. Her temperature and blood pressure were within normal limits. There was obvious swelling of the entire left upper extremity, dilated subcutaneous collateral veins over the anterior shoulder, and mild cyanosis in the hand and fingers. Neurologic and arterial examinations of the upper extremities yielded normal findings. Venous duplex ultrasonography showed an occlusive thrombus in the left subclavian and axillary veins. Computed tomography pulmonary angiography showed pulmonary emboli in the bilateral subsegmental arteries. The patient was admitted, and treatment with low-molecular-weight hep arin was started.The following morning, the patient underwent peripheral venography (Figure 1) with catheter-directed thrombolysis using a tissue plasminogen activator. She subsequently received ongoing anticoagulation with intravenous unfractionated heparin. A follow-up venogram 24 hours after the thrombolysis showed resolution of the clot; however, severe stenosis of the left subclavian vein was noted. Angioplasty of the stenotic area was only partially successful, leaving residual stenosis of the subclavian vein in the neutral position, with dynamic occlusion on abduction of the left upper extremity (Figure 2). Two days later, the patient was discharged home and prescribed low-molecularweight heparin.Two months after discharge, the patient underwent an uncomplicated transaxillary resection of the left first rib to relieve compression of the subclavian vein. Venography performed one month later showed resolution of the subclavian vein stenosis and of the dynamic occlusion (Figure 3). In discussion with her treating physician, the patient elected to complete a further three months of anticoagulation with therapeutic doses of low-molecular-weight heparin instead of transitioning to oral anticoagulation following her surgery. She experienced good functional recovery of her left upper extremity, with no recurrence of DVT.

Paget‐Schroetter syndrome from manual handling at work: Case report and review of the literature

“…In this literature review, there was an association between PSS and repetitive hyper‐abduction or external rotation involving the shoulders. We found associations of PSS with various activities using the shoulders including sports like baseball, 17,35 swimming, 10 and judo 11 as well as occupations such as carpentry, 37 photography, 15 furniture lifting, 40 waiter, 23 and kebab chef 34 . This is consistent with our patient's described physical activities at work which involved frequent luggage loading and unloading.…”

“…The majority of the cases were male (35 males and 10 females) which was consistent with previous reviews. Also, we found indications that the right arm is more often affected than the left or both, as we found 26 cases involving the right arm, 9-34 15 cases involving the left, 12,[35][36][37][38][39][40][41][42][43][44][45][46][47][48] and 4 cases involving both arms. [49][50][51][52] These findings may be a simple reflection of the fact that the majority of the population are right-handed and so it is more likely that the right arm is used more and therefore more susceptible.…”