Extensive venous thrombosis of the upper extremity in a diabetic patient with a hyperosmolar hyperglycemic state
A 38-year-old man with diabetes mellitus presented to the emergency room with a five day history of vomiting, lethargy and drowsiness. 5 days prior to admission he had been drinking heavily. He had a 10 year history of diabetes, treated with an oral hypoglycemic agent.\nOn admission he was afebrile, severely dehydrated and drowsy. No infectious focus was found on clinical examination, and there were no neurological manifestations. Admission laboratory data were notable for a plasma glucose of 1314 mg/dL (72.2 mmol/L), a serum osmolarity of 423 mOsm/kg, a potassium level of 5.1 mEq/L and a creatinine level of 2.1 mg/dL. Arterial blood gas analysis on room air showed a pH of 7.37, PaO2 of 74.5 mmHg, PaCO2 of 53.1 mmHg, and HCO3- level of 30.1 mmol/L. There was 1+ ketonuria. The blood count demonstrated a polycythemia, with a hemoglobin of 20.2 g/dL, a white cell count of 12,400/µL and a platelet count of 256,000/µL. The coagulation screen, PT and aPTT were normal. His electrocardiogram revealed a sinus tachycardia.\nThe diagnosis of a hyperosmolar hyperglycemic state with severe dehydration was made. A right subclavian catheter was placed for fluid replacement in the emergency room. The patient was treated with intravenous insulin, fluid infusion and empirical antibiotics. By the next day, his condition was much improved and he was mentally alert.\nThirty hrs after central venous catheter placement the patient complained of pain in his right arm; moderate edema and erythema of the arm were noted. The right subclavian catheter was removed and the patient was closely observed. On hospital day three, his right arm edema was aggravated, and he developed neck edema. Thrombocytopenia was observed. A color Doppler ultrasonogram of the extremity demonstrated acute thrombosis from the right internal jugular and subclavian veins to the brachial and basilic vein. An upper extremity venogram confirmed occlusion at these sites (). The patient denied any prior history of venous thromboembolism. Coagulation profile studies including plasma prothrombin time, antithrombin III, homocysteine, protein C, protein S, lipoprotein and Factor VIII concentrations were within normal limits.\nThe patient was treated with intravenous heparin and thrombolysis. Thrombolysis was performed using a bolus injection of urokinase, 300,000 units, with a multisided hole infusion catheter positioned at the right basilic and cephalic veins. The thrombolytic infusion was continued overnight via catheter. The next day, a follow-up venogram showed partial lysis of the clot. On discharge, the swelling and pain in the right arm were much improved; the platelet count improved and the patient was kept on warfarin until follow up. Two months later, the patient had no symptoms and the follow up color Doppler ultrasonogram showed no evidence of a thrombus in the previously damaged vein (, ).