Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
A 69-year-old Caucasian male (CM) with a past medical history (PMH) of diabetes mellitus type 2 (DM 2), atrial fibrillation (Afib) on warfarin (Coumadin), and hypertension (HTN) was admitted to the hospital with a chief complaint (CC) of left leg pain. Cellulitis was diagnosed and the antibiotic Unasyn (R) was started. During the hospital stay, the patient was found to have anemia with Hgb 8 mg/dL and guaiac positive stools. A colonoscopy showed diverticulosis and a benign polyp which was removed. Warfarin (Coumadin) was held for 10 days. He was on heparin 5000 U SQ BID.
Why are we presenting this case?
Read on... it will become interesting. An X-ray of the left heel showed osteomyelitis and patient was scheduled for surgery. At the same time, the left calf swelling was not subsiding although patient was afebrile and the WBC was normal (WNL). The d-dimer was 2117, and INR was 1.10.
Does he have deep vein thrombosis (DVT)?
The d-dimer may be elevated due to a lot of different reasons and is not specific for DVT. A left calf DVT was suspected and confirmed by the preliminary Duplex report. Full dose enoxaparin (Lovenox) was started at 1 mg/kg q 12 hrs.
During the second day of LMWH therapy, the patient developed rectal bleeding, passing clots.
How to treat bleeding caused by LMWH?
FFP is not helpful and Protamine is effective in only 50-70% of cases. This is one of the drawbacks of LMWH therapy.
Enoxaprain (Lovenox) was stopped and bleeding gradually resolved. Hgb was stable around 8-9 and he did not need PRBC transfusion. A tagged RBC scan did not show any evidence of acute bleeding.
NM GI Bleeding scan (click to enlarge the image).
The final Duplex report was not convincing of DVT.
Venous Duplex Report-LLE (click to enlarge the image).
What to do now?
Nuclear medicine venous thrombosis scan with TC 99 Accutect, i.e. Accutect scan.
Accutect did not show an acute DVT.
NM Accutect scan for DVT (click to enlarge the image).
The patient had a persistent AFib and the rate was controlled. For now he will be on Plavix and ASA. His anticoagulation with Coumadin (very risky given the history) will be discussed with the GI and Cardiology consultants.
What did we learn from this case?
Anticoagulation is risky. Starting Coumadin for someone with DVT opens a whole new bag of worms and changes their life for at least 6 months. It is not an easy decision to make and that's why we have to be sure. If the Duplex is not conclusive you have to do an Accutect scan.
Oral rivaroxaban is non-inferior to standard therapy for symptomatic pulmonary embolism (PE) and DVT (NEJM, 2012).
Phlegmasia Cerulea Dolens. NEJM, Volume 356:e3, January 18, 2007, Number 3.
Cheney treated for blood clot in his leg. CNN, March 5, 2007.