DVT AND THALASSEMIA

Case presentation

Patient general informations: Name اسيل جعفر خضير Age:33 years Sex:female Occupation:House wife Residency:Najaf/ AL Zahra Q Religion:Muslim Marital status:Married G2 P2 A0 Date of admission:22/10/2013

Chiefcomplaint :sever left leg pain for few hours duration before admission to hospital Chief complaint : sever left leg pain for few hours duration before admission to hospital

History of present illness: The condition started as mild to moderate pain in left leg and mild lower abdominal pain 24 hrs and consulted her gynecologist because she is pregnant in 7 th missed period with history of DVT in last pregnancy and told her it is simple muscle cramp not need treatment. In mid night at day of admission she had moderate to sever pain in left leg,rapid progression to became sever,continuous pain,burning in nature mainly in medial aspect of leg aggravate by walking,not improve by rest,not associated with any fever or systemic illness,in early morning became more sever pain with mild leg swelling at this time patient admitted to our hospital,in medical ward rapid progression of leg swelling and more tenderness with prominent of linear red discoloration which is more tender area. in next day of admission more significance swelling ( two legs circumference difference 6 cm ) and she had new tender area with red discoloration linear shape about 10 cm in medial aspect of right thigh without swelling.after 2days of last lesion patient had new lesion with same feature in suprapubic area.

patient is a known case of Thalassemia diagnosed during her early childhood for which she need frequent blood transfusions, splenectomy was done at age of 15 after which she never need blood transfusion. She was kept on folic acid only and she had a normal life. The patient got married 3 yr ago, she did not use any contraception method, she became pregnant after 9 months without history of fetal loss or infertility At presentation the patient was in her 7 th missed period. The patient was started on anticoagulation in form of LMWH (Enoxaparine), the swelling continue to progress over the first 3 days, we increase the dose of anticoagulation and antibiotic the Pt. respond within 7 days. She had same condition in last pregnancy before 2 years but the lesion in left side only

System review: CNS:Unremarkable Respiratory :Unremarkable GIT:Unremarkable CVS:Unremarkable Renal s.:Unremarkable Musculoskeletal s.:Unremarkable

Past medical history: DVT, Thalassemia Drug history: LMWH (Enoxaparine), warfarin, Folic acid Family history:. Uncle → Thalassemia, died. Past surgical history Splenectomy Social history: unremarkable

On examination: General examination:Conscious, alert, pale, no LAP Vital signs:PR:85BP: 110/70Temp:37,4 Chest:Clear Heart:Normal double rhythm, no added sounds. Abdomen:Distended (pregnant) Extremity: Swelling of LT leg extending to knee joint, pitting, red discoloration in the upper medial side of her leg, tender, prominent veins tender cord like appearance in medial aspect left leg and right thigh, intact pulses

Investigations:

CXR  Normal

BS: 112 mg/dl BU: 25 mg/dl SC:0.9 mg/dl CBP& blood film : WBC: 36000,, PCV: 0.23,, Retic: 15 RBC: hypo chromic cells with anisopoikelocytosis and some oval cells, target cells and many monocytes.. WBC: leukocytosis with neutrophilia and no primitive cells.. Platelet normal count and shape..

Ham’s test -ve INR 1.1 Pt. 14 Ptt. 23 HBsAg -ve ANA -ve Anti cardiolipin Ab. -ve Anti phospholipid Ab. -ve

Thrombotic Complications In recent years there have been numerous reports of thromboembolic complications in thalassemia. In a multicenter study the frequency of thromboembolic events was found to be 4% in patients with thalassemia major and 10% in patients with thalassemia intermedia. Other groups have reported similar prevalences In a large study of 8,860 patients from different countries, female sex, previous splenectomy, and profound anemia were found to represent risk factors. A chronic hypercoagulable state has been observed even in childhood. It has been demonstrated that procoagulant phospholipids are exposed on the surface of the red cells and that platelets and the hemostatic system are activated in thalassemia major and intermedia. In addition, vascular endothelial cell injury and the peroxidative status due to iron overload have been possible pathogenetic mechanisms. Concomitant prothrombotic conditions are frequently present in thalassemia patients after the first decade of life: Insulin-dependent diabetes, estrogen therapy, atrial fibrillation, and postsplenectomy thrombocytosis, among others. A thorough review of the literature on the mechanisms of the hypercoagulable state present in thalassemia has been published. But no Prophylactic measures have been proposed …