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WELCOME�TO �CLINICAL CASE PRESENTATION

Department of Haematology

BSMMU

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�

Presented by

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Dr. Mehnaj Ashraf

Phase-B Resident

Dept. of Haematology, BSMMU

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A 64-year-old male with DVT and acute visual loss

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Particulars of the Patient

Name : Mr. Murad Sheikh

Age : 64 year

Sex : Male

Religion : Islam

Marital Status : Married

Occupation : Businessman

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Chief Complaints

  • Sudden loss of vision for 1.5 months
  • Left lower limb swelling for 3 months
  • Exertional dyspnea and dry cough for 6 months

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History Of Presenting Illness

  • Loss of vision for 1.5 months
  • Sudden onset
  • Painless
  • First Right eye
  • Followed by decreased visual aquity left eye

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History Of Presenting Illness�

  • Left lower limb swelling for 3 months
  • Sudden onset
  • Painful
  • Initially confined to calf
  • Then extended up to mid thigh
  • No: Fever

Rash

Joint Pain

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History Of Presenting Illness�

  • Exertional Dyspnoea

-Insidious onset

-Gradually increasing

-Dry Cough

-No: Chest pain

Lying posture

Fever

Haemoptysis

Diurnal variation

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No History

  • Malignancy
  • Surgery
  • Trauma
  • Previous H/O VTE
  • Family history of VTE

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History of Past Illness

History of Covid -19 in one year back and received 2 dose of covid -19 vaccine

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Treatment History

  • S/C Enoxaparin was given for 5 days then oral warfarin started 10mg loading dose followed by 5mg/daily
  • After 3days of starting warfarin, the patient's INR 5.72 and the patient developed hemoptysis with reduced Hb (6.9g/dl)
  • RCC 4 unit was given
  • Oral Apixaban 5mg/daily started and continued

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Personal History

  • Ex-smoker (5pack year, quit 30-year back)

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Family History

  • No Significant

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General Examination�

Anemia

Pulse 72 (regular) all peripheral pulse are normal

BP 140/70 mmHg

SpO2 94%

Respiratory Rate 20 br/min

Temp 980F

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Examination of the lower limbs

  • Left lower limb was swollen with engorged superficial veins
  • There was venous ulceration over the dorsal aspect of the left foot
  • No hyperpigmentation
  • No trophic skin changes
  • Some tenderness

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Neurological Examination

Weakness on dorsiflexion of Rt. Foot (MRC 3/5)

Touch and pain sensation were diminished

Joint position vibration intact

Jerk diminished in both lower limbs

Bilateral planter response equivocal

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Examination of the eye

  • Visual acuity of the right eye was non-perception to light and 6/60 in the left eye
  • Pupillary light reflex was absent in the right eye and brisk in the left eye
  • Ocular movement : Normal
  • Fundoscopic examination :

Right Eye: Retinal whitening with hemorrhage and cotton wool spots compatible with CRAO

The left eye : Exudate

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Respiratory System Examination

  • Vesicular breath sound with prolonged expiration with scattered crepitation

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Investigations

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� Complete blood count

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Name of Investigation

Result

Normal Value

Hb%

10.8 gm/dl

12-16 gm/dl

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ESR

81 mm in 1st hour

0-20 mm in 1st hour

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WBC Count

18100/Cu mm

4000-11000/Cu mm

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Differential Count of WBC

N- 73%, L-07%

M- 2%, E- 18%,

B- 00%

N- 40-75%, L-20-50%, M- 2-10%, E- 1-6%,

B- 0-1%

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Platelet Count

331000/Cu mm

150000-400000/Cu mm

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The Coagulation Profile

Test

Result

Reference value

Protein S

15%

90-130%

Protein C

70%

70-130%

Anti-thrombin ӀӀӀ

130%

80-120%

Serum Homocysteine

14.1

5.46-16.20µmol/L

JAK2 V617F mutation

negative

 

IgG

12.3

7.67-15.90g/l

IgM

0.304

0.37-2.86g/l

IgA

0.623

0.61-3.56g/l

C3

0.776

0.9-1.8g/l

C4

0.303

0.1-0.4 g/l

Protein electrophoresis

Alpha-2 region raised

 

Coomb’s test

(Direct&indirect)

Negative

 

APTT

30

20-40 Seconds

Fibrinogen

421

200-400 mg/L

cANCA

Negative

 

pANCA

Negative

 

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Normal reports

  • Liver function tests
  • Trop I
  • Pro BNP
  • S. Creatinine
  • S. Electrolytes
  • LDH
  • S. Folate
  • Vit B-12

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Color Doppler Study of Lower Extremity Veins

Left lower limb

  • Chronic thrombus with partial recanalization is seen in left Common Femoral Vein
  • Lumen occluding Chronic thrombus with smaller superficial femoral vein is noted in mid third of thigh
  • No reflux is seen in sapheno-popliteal junction

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Right Lower Limb

  • No Doppler evidence of DVT
  • Normal blood flow pattern

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Comment: Optic atrophy on Right Eye and pale disc in Left Eye. A suspected case of CRAO of RE which may due to Pulmonary Embolism

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Colour fundus photography (CFP) and FFA Fluorescein Fundus Angiography

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HRCT of Chest (1/9/21)

Ground glass opacities with septal thickening and few fibrotic band are noted in different segments of both lung field predominantly in the peripheral region Bilateral Pulmonary inflammatory lesion ( Lung involvement is about 30%)

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  • Nerve Conduction Study

Severe Sensory Motor PolyNeuropathy ( both axonal and demyelinating ) lower limbs are more affected

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MRI with brain with contrast � Sub acute infract at left parietal region �

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Echocardiogram

NO RWMA at rest

LVEF 62%

Mild TR (PASP 35-40 mm)

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Diagnosis

  • A central retinal artery occlusion
  • Ischemic cerebral infarction
  • Deep vein thrombosis (left femoral vein), and venous ulcer of the left leg due to protein S deficiency
  • For Respiratory Complain

D/D: Chronic PE

Post Covid Fibrosis

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