Incidental Finding of Inferior Vena Cava Atresia Presenting with Deep Venous Thrombosis following Physical Exertion.

Inferior vena cava atresia (IVCA) is a rare but well described vascular anomaly. It is a rare risk factor for deep venous thrombosis (DVT), found in approximately 5% of cases of unprovoked lower extremity (LE) DVT in patients <30 years of age. Affected population is in the early thirties, predominantly male, often with a history of major physical exertion and presents with extensive or bilateral DVTs. Patients with IVC anomalies usually develop compensatory circulation through the collateral veins with enlarged azygous/hemizygous veins. Despite the compensatory circulation, the venous drainage of the lower limbs is often insufficient leading to venous stasis and thrombosis. We describe a case of extensive and bilateral deep venous thrombosis following physical exertion in a thirty-six-year-old male patient with incidental finding of IVCA on imaging.

Impact of Asthma on the Severity of Serious Pneumococcal Disease.

We recently reported an increased risk of serious pneumococcal disease (SPD) in asthmatics. Little is known about the impact of asthma status on the severity of SPD. We compared the severity of serious pneumococcal disease (SPD) between patients with asthma and those without asthma. The study subjects were Rochester, Minnesota residents who developed SPD between 1964 and 1983. SPD and asthma status were ascertained by using explicit predetermined criteria Severity of SPD was assessed using intensive care unit (ICU) admission rate and total days of ICU stay and hospitalization associated with treatment for SPD. We found that there were no significant differences in severity outcomes between asthmatics (n=11) and non-asthmatics (n=163). Asthma status may increase the risk of SPD but not influence its severity. However, given a small sample size of our study, a larger study needs to be considered to clarify the relationship between asthma and severity of SPD.

Two cases of upper-extremity swelling: Paget-Schroetter syndrome and non-Hodgkin lymphoma.

Two adolescents presented to our emergency department with isolated, acute onset upper-extremity swelling. In their initial emergency department evaluations, both patients were found to have a deep venous thrombosis. Despite their similar presentations, the etiologies of their deep venous thrombosis were very different. After further evaluation, one patient was diagnosed with Paget-Schroetter syndrome and the other with non-Hodgkin lymphoma. These cases illustrate the importance of maintaining a broad differential diagnosis and using a multidisciplinary approach to patients with the unusual and potentially life-threatening presentation of upper-extremity swelling.

Acute deep vein thrombus due to May-Thurner syndrome.

A 63-year-old white woman with a history of hypertension, hyperlipidemia, hypothyroidism, and transient ischemic attack, on Premarin, presented with a 2-week history of worsening edema and pain on the left side of the lower extremity associated with purplish discoloration and decreased temperature after a prolonged car travel. Physical examination revealed 2+ edema from the midthigh to the toes associated with purpuric discoloration. All arterial pulses were 4+. Ultrasound examination demonstrated an acute deep vein thrombus extending from the external iliac veins down throughout the visualized veins of the left calf. The patient was started on intravenous heparin and underwent venogram with subsequent thrombolysis. After 48 hours of alteplase infusion, balloon angioplasty was performed and 2 stents were placed in the left common and external iliac veins. Premarin was discontinued and she remains on oral anticoagulation with Coumadin. The patient did well clinically and a second ultrasound showed interval improvement. There is significant family history but no personal history of thrombotic events; however, thrombophilia evaluation is unremarkable.

Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?

OBJECTIVES: To assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients. METHODS: Data was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006. RESULTS: The final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59-82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC+AP). Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24s; p<0.001). Similarly patients on AC+AP also had higher INR (median 1.9) and aPTT (median 30s) when compared to those not on AC/AP (p<0.001). Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm(3)) when compared to those not on either AC/AP (median 27.2 cm(3); p=0.05). The same was not found for patients using AP (median volume 20.5 cm(3); p=0.813), or both AC+AP (median volume 27.7 cm(3); p=0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04-1.98; p=0.035). There was no relationship between the use of AC/AP/AC+AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0-3.03; p=0.05). No relationship was found between use of AP or AC+AP use and mortality. Of the 82 patients with INR>1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24h (median 1.2, IQR 1.1-1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death<7 days) or functional outcome. CONCLUSIONS: Anticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.

Acute vomiting and mental status changes: a case of acute intraventricular haemorrhage from an optic chiasm tumour.

In this article, we describe a 5- year-old girl who presented to an emergency department with 1 day of vomiting, mental status changes and decreased activity. Imaging studies revealed a mass in the optic chiasm which had haemorrhaged into her ventricles causing acute hydrocephalus. This case highlights the diligence and broad differential one must have when evaluating a child presenting with a sole complaint of vomiting.