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Case Study

Deep Vein Thrombosis in Tuberculosis


Santosh Ghai*, Ritin Mohindra*, Neelima Jain**
Abstract
Pulmonary tuberculosis is very prevalent in developing countries but its thrombogenic
potential is a new entity. There are a few reports stating the relation of deep vein thrombosis
(DVT) with pulmonary tuberculosis (PTB). We are presenting a case series of three patients
with different forms of tuberculosis presenting with DVT having no risk factor for
hypercoagulability. We are highlighting an under-reported phenomenon so that high
suspicion, adequate prophylaxis and prompt management of DVT can play a vital role in the
survival of this subset of patients.

Keywords: Pulmonary tuberculosis, Deep vein thrombosis.

Introduction
India accounts for almost one-third of the global burden clinical signs suggestive of DVT were present. Color
of tuberculosis.1 Although the epidemiology and natural venous Doppler of the lower limb showed echogenic
history of the disease have been extensively described, lumen in common femoral vein, saphenofemoral vein
a hypercoagulable state has not been emphasized. and popliteal vein. The lesion showed absence of distal
Tuberculosis continues to remain challenging with a compressibility. Venous system of the right leg was
variety of clinical presentations of which systemic normal. Routine investigations revealed anemia 9 g/dL
hematological complications, like disseminated intra- with thrombocytosis 5.03 lakh/mm3, and an increased
vascular coagulation (DIC) and deep vein thrombosis, ESR 73 mm/hr. Her detailed coagulation profile was sent
are quite rare.2,3 DVT is clinically observed and can be for and was found to be deranged: D-Dimer 841(0–360),
confirmed with laboratory methods in 3-4% of patients FDP >300 mg/mL, PT 11.85 sec, INR 0.98, and aPTT 22.1
with pulmonary tuberculosis related to hypercoagulable sec. The patient was started on LMWH and overlapped
state secondary to the inflammatory state. The real with warfarin on fifth day. The patient showed
incidence may be closer to 10% because most of the improvement in pain and swelling after 6 days of
patients are thought to be clinically in-apparent.4 The anticoagulant therapy. She was discharged on 4-drug
lack of awareness regarding the association is possibly ATT and oral anticoagulants with a target INR 2.0–3.0.
responsible for the condition not being recognized, and The patient was subsequently lost to follow-up.
hence, screening and treatment strategies have not
been standardized. Case Number Two

Case Report A 25-year-old male smoker and occasional alcoholic a


k/c/o old treated PTB diagnosed two and a half years,
Case Number One presented with complaints of intermittent low-grade
fever with evening rise of temperature for 6–7 months,
A 16-year-old unmarried female diagnosed to have minimal non-productive cough associated with
sputum positive pulmonary tuberculosis 10 days back exertional dyspnea for 3–4 months. There was no
presented to us with the complaints of painful left lower history of hemoptysis. He had now developed painful
limb swelling for the past 7 days. The patient was swelling of his lower limbs left>right for 6–7 days. There
already on 4-drug anti-tubercular treatment at was no history of prolonged immobilization, long travel
presentation. There was no history of long journey, or recent surgery or history suggestive of connective
trauma or recent surgery. She was a non-smoker or tissue disease. Examination revealed a poorly built,
alcoholic. On examination the swelling was tender and malnourished male with stable vitals.
*
Senior Resident, Department of Medicine, Unit 3A, VMMC and Safdarjung Hospital.
**
Professor, Department of Medicine, Unit 3A, VMMC and Safdarjung Hospital.
Correspondence to: Dr Santosh Ghai, Department of Medicine, Unit 3A, VMMC and Safdarjung Hospital.
E-mail Id: santosh_ghai@yahoo.com

© ADR Journals 2015. All Rights Reserved.


J. Adv. Res. Med. 2015; 2(3) Ghai S et al.

Respiratory examination was notable for the presence lower lobe, and bronchiectatic changes in left upper
of coarse crepitations in bilateral basal regions. There lobe and necrotic conglomerate nodes in subcarinal
was bilateral pedal edema extending from inguinal region. There was no evidence of pulmonary embolism.
region. Signs for DVT were positive in both legs. His CECT abdomen showed left femoral vein, external iliac,
venous Doppler revealed extensive echogenic thrombus common iliac vein not opacified with filling defect
extending from IVC to bifurcation distal to bilateral extending to IVC proximally till the level of right renal
popliteal veins. Investigations revealed a hemoglobin vein, and bilateral renal veins normal in caliber and
level of 10.1 g/dL, total leukocyte count 13,500/mm3, opacification. Patient was started on CAT 1 ATT under
differential-polymorphs 87%, lymphocytes 10%, and DOTS regimen along with enoxaparin. She was
platelets 231,000/mm3. Peripheral blood smear was overlapped with acitrom till therapeutic INR was
normal. Renal and liver function tests were normal. reached. Patient was discharged after 2 weeks, as she
Coagulation profile was abnormal: D-Dimer was >4 responded to the treatment with improvement in her
mcg/mL, PT 10.7, INR 0.97, APTT 20.7 sec. ABG revealed breathlessness and lower limb swelling, to follow up in
hypoxia. Chest radiograph revealed cavity in left upper medicine OPD.
zone and extensive infiltration in right lung. Computed
tomography (CT) of the chest revealed nodular opacities Discussion
in both the lungs and cavitory lesions in left upper lobe
with necrotic lymph nodes. Patient was started on Pulmonary tuberculosis is one of the most prevalent
empirical parenteral third-generation cephalosporin, diseases in our country. If advanced, its complications
along with LMW heparin while sputum reports were are vast to counteract. However, hemostatic
awaited. Meanwhile, sputum for acid-fast bacilli was complications are very rare and thrombogenic potential
positive, and the patient was started on CAT-2 5-drug of tuberculosis is not frequently documented in
ATT daily regimen as per body weight and overlapped literature but can have serious consequences. Reports
with warfarin with target INR of 2–3. Patient responded demonstrate the association between inflammation and
well and was discharged after 10 days to follow up in hemostatic changes arising in PTB that could result in a
medicine OPD. hypercoagulable state which might predispose to
thrombotic phenomena. It not only involves venous
Case Number Three thromboembolism but thrombosis also in hepatic veins,
the vena porta, the inferior vena cava, cerebral venous
A 25-year-old female presented with c/o low grade sinuses, and the central retinal vein. Disseminated TB
fever on and off for the last 3 months associated with may induce at the peripheral blood the activation of
breathlessness for 15 days. She was evaluated and mononuclear cells, which interact with mycobacterial
diagnosed to have pulmonary TB and started on ATT products inducing increased synthesis of factor tumor
which she stopped by herself after taking the drugs for necrosis alpha and interleukin-6.5 Various studies have
15 days. She had now developed swelling and redness concluded that the high level of plasma fibrinogen,
of her left lower limb along with pain and now impaired fibrinolysis associated with a decrease in
presented to our hospital. She was mobile and there antithrombin III, protein C and platelet aggregation
was no history of trauma, long travel or prolonged appear to induce a hypercoagulable state promoting the
immobilization. development of deep vein thrombosis in pulmonary
tuberculosis.6 Some authors have mentioned the high
Examination revealed diffuse crepitations all over chest incidence of antiphospholipid antibodies and
and swelling and tenderness of the thigh region of left hypoprothrombinemia in appreciable number of cases.
lower limb. Signs of DVT were positive. Investigations Cytokines by their pro-inflammatory character will
done showed mild anemia with hypoalbuminemia with activate the vascular intima and make thrombogenic
normal remaining blood profile. D-Dimer was elevated. endothelium. They will also lead to a stimulation of
Imaging tests-USG abdomen-revealed multiple hepatic synthesis of coagulation proteins.5 These risks of
mesenteric lymphadenopathy and features s/o cystitis. hypercoagulability are increased by immobility and bed
USG Doppler showed significant thrombus and non- rest because of the morbidity caused by the disease.
compressibility in left CFV, SFV, popliteal and posterior
tibial veins up to mid-calf region sparing distal calf along These hemostatic changes improve during the first
with extension of thrombus into the external iliac vein, month of TB treatment and for this reason, it should be
common iliac up to inferior vena cava. CECT chest immediately started in addition to anticoagulant
showed consolidation with cavitation and bronchiectatic therapy.
changes in right upper, middle and superior segment of

5 ISSN: 2349-7181
Ghai S et al. J. Adv. Res. Med. 2015; 2(3)

Conclusion References
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and severe forms. Prophylactic anticoagulation finds its with hypercoagulable state due to tuberculosis.
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Source(s) of Support: Nil Association thromboses veineuses profondes avec
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Conflict of Interest: Nil 328-29.

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