Superficial Venous Thrombosis

ID: 36y/o healthy female, came in with Lt leg pain. 

HPI: Sudden onset of pain, Lt leg 5/7, constant, stabbing, no swelling; no SOB; no cough/hemoptysis; no CP; no fever/chills; does not interfere with mobilization; no recent trauma/surgery; no IVDU; 

PMH: Endometriosis on Cyclomen (danazol) ✗ 2yr; no Hx of DVT, PE, clotting disorders; 

FH: noncontributory.

E/O: A+O ✗ 3 - NAD - ⊘ill/toxic

BP: 118/76 P: 86  R: 18  SAT: 98% RA  T: 36.7 ℃

Significant localized tenderness on the upper anteromedial aspect of the Lt leg; equal leg circumference on both sides;  no colour changes, Lt leg not warmer than the contralateral side; no calf tenderness; dorsalis pedis/pos. tibial pulses symmetrical; capillary refill normal.

CVS, Resp, Abdo exams unremarkable.

CBCD, Rapid Metabolic Panel (RMP), INR, all Ⓝ

U/S ➜ 2cm clot in the saphenous vein; no DVT; 

I/P: 36 y/o healthy ♀ with superficial venous thrombosis (SVT) precipitated by danazol. 

Stop danazol; pain management (warm/cold compress, elevation, compression stockings, NSAIDs); discuss pros and cons of NSAIDs alone vs full anticoagulation ✗ 4wk; F/U with GP in 7-10 days; discharge home with F/U precautions;   

Discussion ⁽¹⁾: 

Increased risk of thromboembolism if, ≤5cm from the saphenofemoral/saphenopopliteal junction (deep venous system), thrombus ≥5cm in length, +ve medical risk factors for DVT; These patients may benefit from anticoagulation (Rx decision should be individualized); otherwise Rx with NSAIDs, pressure stockings, elevation, warm/cold compress.

Optimum agent,dose, duration unclear; fondaparinux, UFH, LMWH, and warfarin all effective and can be used.

Repeat U/S may be necessary based on physical exam and physician’s discretion.

Remember DVT can occur in the ipsi- or contralateral lower limb in patients with SVT. 

Reference: 

1. http://www.uptodate.com/contents/superficial-thrombophlebitis-of-the-lower-extremity?source=preview&anchor=H20&selectedTitle=1~54#H20