Case Report
Multiple Venous Thromboses Presenting as Mechanical Low Back Pain in an 18-Year-Old Woman

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Abstract

Objective

The purpose of this case report is to describe a patient who presented with acute musculoskeletal symptoms but was later diagnosed with multiple deep vein thrombosis (DVT).

Clinical Features

An 18-year-old female presented to a chiropractic clinic with left lumbosacral pain with referral into the posterior left thigh. A provisional diagnosis was made of acute myofascial syndrome of the left piriformis and gluteus medius muscles. The patient received 3 chiropractic treatments over 1 week resulting in 80% improvement in pain intensity. Two days later, a sudden onset of severe abdominal pain caused the patient to seek urgent medical attention. A diagnostic ultrasound of the abdomen and pelvis were performed and interpreted as normal. Following this, the patient reported increased pain in her left leg. Evaluation revealed edema of the left calf and decreased left lower limb sensation. A venous Doppler ultrasound was ordered.

Intervention and Outcomes

Doppler ultrasound revealed reduction of the venous flow in the femoral vein area. An additional ultrasonography evaluation revealed an extensive DVTs affecting the left femoral vein and iliac axis extending towards the vena cava. Upon follow-up with a hematologist, the potential diagnosis of May-Thurner syndrome was considered based on the absence of blood dyscrasias and sustained anatomical changes found in the left common iliac vein at its junction with the right common iliac artery. A week following discharge, she presented with chest pain and was diagnosed with venous thromboembolism. The patient was successfully treated with anticoagulation therapy and insertion of a vena cava filter.

Conclusion

Although DVTs are common in the general population, presence in low-risk individuals may be overlooked. In the presence of subtle initial clinical signs such as those described in this case report, clinicians should keep a high index of suspicion for a DVT. Rapid identification of such clinical signs in association with a lack of objective examination findings warrants further evaluation due to potentially negative outcomes.

Introduction

Venous thromboembolism (VTE), a blood clotting process that encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common vascular disorder in white populations after myocardial infarction and stroke.1 An individual’s absolute lifetime risk of VTE is approximately 11%2 and its incidence rate increases exponentially with age, for both women and men.1, 3, 4 Although less frequent than DVT alone (0.93 per 1000 person-years), PE with or without DVT (0.50 per 1000 person-years)1 has a higher recurrence rate and is often fatal.3 Most cases of DVT (90%) are located in the lower limbs,5 particularly within the gastrocnemius and soleus muscles6 and become symptomatic when there is proximal vein involvement.5 Despite adequate treatment, DVT can recur, and about 10% of patients will develop severe post-thrombotic syndrome within 5 years.7 As part of the general chiropractic program, the training on VTE includes education on the usual clinical presentations, such as a “red, swollen, and hot” calf for DVTs and shortness of breath for PEs. Clinicians should be aware of the different clinical presentations of this serious pathology, as faster diagnosis and treatment may lead to a better prognosis.

The objective of this case report is to present a rare case of multiple thromboembolism events in a young woman, who first presented to a chiropractor’s clinic for acute low back pain. An overview of the risk factors, clinical presentation, diagnosis, and management will be discussed.

Section snippets

Case Report

An 18-year-old woman presented to a chiropractic clinic with left lumbosacral pain with referral into the posterior aspect of the left thigh. The pain had started suddenly, 72 hours before the consultation as the patient was pulling a cable out of the swimming pool. The pain occasionally extended below the knee with forward bending of the lumbar spine. However, the patient did not report any numbness, paresthesia, or weakness in the lower extremities. The patient characterized the nature of her

Discussion

In light of the events mentioned above, primary care physicians should recognize the importance of conducting a detailed history and physical examination when vascular peripheral involvement is suspected. The physician should screen the patient's past history for personal or family antecedents of vascular disease and known blood anomalies. Screening for potential risk factors and use of the Wells probability score (detailed in the “Diagnosis” section) should help clinicians estimate the

Limitations

Due to its nature, a case report does not allow for potential associations nor cause and effect. However, it may provide insight into clinical presentations that differ from what is usually expected. The patient experienced sudden pain following a physical effort and did get some relief from conservative chiropractic treatments. It is possible that the occurrence of the deep vein thromboses is purely coincidental and had nothing to do with the initial event and patient presentation.

Conclusion

Although VTE is a common condition in the general population, its presence in low-risk individuals can be overlooked. In the presence of subtle initial clinical signs such as those the patient in this case report presented with, clinicians should keep a high index of suspicion for a DVT. Rapid identification of such clinical signs in association with a lack of objective examination findings warrants further evaluation due to potentially negative outcomes.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

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