Venous thrombosis in subclavian, axillary, brachial veins with extension to internal jugular vein, right sigmoid sinus and simultaneous pulmonary embolism
A 79-year-old man admitted in Alzahra University Hospital, Isfahan, Iran for left upper extremity swelling since 2 weeks ago. He also complained of sudden onset dyspnea and cough. After 2 days, he experienced a generalized tonic colonic seizure with left-side hemiparesia and sudden onset impairment in his visual field. He had a history of chronic obstructive lung disease, chronic history of cigarette smoker and systemic hypertension. At the time of admission, he had no respiratory distress with stable vital signs but decreased respiratory sound on auscultation in bilateral lower lung fields. Laboratory tests showed peripheral white blood cells 7,600/mm3, (4000-8000) hemoglobin 11 g/dL (normal level between 14 and 16), and platelets increased to 157,000/mm3 (150,000-450,000) Arterial blood gas analysis under 2 L/min oxygen supply showed pH 7.459, PaCO2 38.9 mmHg, and PaO2 79.5 mmHg. Serum D-dimmer value was increased to 9.02 μg/mL (Normal <4 μg/mL). Color duplex sonography of the neck veins and proximal veins of left arm was revealed hypoechoic and mobile thrombosis occluded the left Internal Jugular Vein (IJV) which extended to sub-clavian, axillary, brachial veins []. There was no evidence of thrombosis in the lower extremities. At first, Contrast-enhanced multi-slice multi-detector computed tomography (MSCT) revealed no thrombus in pulmonary vasculatures. During the first week, his symptoms were gradually improved with full anticoagulation by LMWH, (Enuxaparin 60 mg Subcutaneous q12 hours hospital after 5 days, he suddenly developed respiratory distress, progressive dyspnea with hypoxemia without any changes in hemodynamics. Repeated MSCT showed right segmental pulmonary embolism with involvement of sub-segmentary vessels. He was transferred to intensive care unit and the patient's management continued with anticoagulation and his symptoms improved within 1 week. After 2 months repeated venous duplex revealed evidence of resolution following appropriate anticoagulation.