26 March 2023: Articles
Unusual clinical course, Challenging differential diagnosisNawaf Alammari1ABCDEF*, Mohammed Alshalhoub1ABCDEF, Mohanad Aleeban1ABCDEF
Am J Case Rep 2023; 24:e938677
BACKGROUND: Deep vein thrombosis (DVT) is a potentially fatal condition that occurs in 100 persons per 100 000 population, and accounts for 60 000 deaths per year in the United States, making its evaluation and diagnosis essential. Diagnosing DVT can be challenging due to symptom variations between patients. There are no previous reports of DVT patients presenting with foot drop in the literature. Therefore, the purpose of this case report is to present an unusual presentation of DVT in a middle-aged man with no clearly identifiable risk factors for DVT.
CASE REPORT: A 54-year-old otherwise symptom-free male smoker (for 30 years) presented to the Emergency Department complaining of pain in the left leg, which then escalated to weakness and decreased sensation in the left foot. However, he was able to walk with limping. Upon his presentation to the Emergency Department, he stated that his left leg felt quite weak. The neurological examination did not show any remarkable results, except for unilateral limb weakness. After that, a point-of-care ultrasound was carried out, which showed the possibility of non-compressible veins; then, a D-dimer test was conducted. When it tested positive, an official ultrasound was done, which showed thrombi in the left external iliac and common and superficial femoral veins.
CONCLUSIONS: This study reported a unique presentation of foot drop due to DVT in a middle-aged man, with the absence of known risk factors. Utilizing point-of-care ultrasound is a valuable tool in the evaluation of acute unilateral lower limb weakness.
Keywords: Venous Thrombosis, Muscle Weakness, Tomaculous Neuropathy, Peroneal Neuropathies, Middle Aged, Humans, Male, Leg, Femoral Vein, Thrombosis
Deep vein thrombosis (DVT) is a potentially fatal condition that occurs in 100 persons per 100 000 population and accounts for 60 000 deaths per year in the US, making its evaluation and diagnosis essential . Each year, around 123 000 patients with DVT visit Emergency Departments (EDs) in the US, and this number is increasing . Patients with DVT can present in many ways, including with pain, erythema, swelling, or numbness, although these symptoms can sometimes be difficult to detect . An unusual development of DVT was documented in the literature, in which a young male patient developed DVT 4 months after collateral ligament reconstruction surgery . The risk of developing DVT is related to venous stasis, hypercoagulability, or endothelial injury. Diagnosis of DVT starts with pre-test probability estimation, according to the gestalt of an experienced clinician, in conjunction with D-dimer and venous ultrasound. Late diagnosis of DVT can lead to multiple comorbidities, the most lethal of which is pulmonary embolism (PE) . Unilateral foot drop mostly results from neurologic, muscular, or traumatic causes, and there are no previous reports of DVT patients presenting with foot drop in the literature. Therefore, the purpose of this case report is to present the unusual presentation of DVT as foot drop in a middle-aged man with no clearly identifiable risk factors for DVT.
Our case study concerns a 54-year-old, otherwise symptom-free male who had been a smoker for 30 years, with a previous history of stab wound to the left upper quadrant of the abdomen and the right thigh back, from when he was working in the military. The patient’s BMI was 25.53 kg/m2. The patient presented to the ED complaining of pain in the left leg, which had started suddenly 2 days earlier, right after he woke up from sleep. It was initially only pain, which then escalated to weakness and decreased sensation in the foot. According to the patient, the pain radiated to the knee and worsened when he put weight on it. When the weakness started, he was able to walk on it with limping; however, upon his presentation to the ED, he stated that his left leg was completely weak.
The patient denied having pain on the right leg or back. There was no history of trauma, fall, recent surgery, recent long travel trips, or weight loss. There was no family history of similar complaints or coagulation-related diseases. Also, the patient denied any history of fever, insect bite, nausea, vomiting, diarrhea, dysuria, hematuria, alcohol use, or use of any other illicit drug.
Upon examination, the patient’s vitals were grossly stable. His heart rate was 100, his blood pressure was 121/80 mmHg, his O2 saturation was 97% in room air with a respiratory rate of 19 breaths per minute, and he was afebrile. Upon examination, he lay on the bed with a palpable peripheral pulse, and his chest was clear with equal bilateral air entry and no added sound. Back examination was unremarkable for tenderness, and the patient had an intact rectal tone with no saddle anesthesia. Further examination of the skin for any redness, swelling, needle pricks, bites, or wounds was also unremarkable. Neurological examination showed left lower motor weakness of 3 out of 5, associated with foot drop when compared with the right side, which was 5 out of 5. Lower limb sensory examination showed decreased sensation in the left lower foot when compared with the right at the level of the ankle and below with no distinct dermatomal distribution. Knee reflex was examined, and was found to be normal. Ankle reflex was not examined. The upper motor and sensory functions were normal. The cerebellar exam was unremarkable, except that he limped while walking due to his inability to put weight on his left lower leg.
The patient’s laboratory test results (Table 1) were unremarkable. Considering these results, we saw no obvious cause for the weakness, so a point-of-care ultrasound (POCUS) was carried out by an emergency physician. The POCUS showed the possibility of non-compressible veins in the left lower leg. As the patient had a modified Wells score of zero, a D-dimer was measured. Despite the unorthodox presentation, it returned as 1.35, so a DVT ultrasound scan was carried out, which showed thrombi in the left external iliac and common and superficial femoral veins. The left popliteal, posterior tibial, and proximal greater saphenous veins were patent, as shown in Figures 1–3. The patient was admitted to the general ward for observation, and enoxaparin 70 mg twice daily was initiated. Laboratory tests investigating a hypercoagulable state came back negative. Hematology was consulted, and they recommended that the patient be followed in the clinic after repeating the laboratory tests, to follow the course of the illness. After around 10 days, the patient was discharged on apixaban, free of symptoms, including foot drop.
However, 40 days later, the patient presented to the ED complaining of right lower chest pain, pleuritic in nature, with a heart rate of 115 bpm and an electrocardiogram (ECG) showing sinus tachycardia with S1Q3T3. The patient’s laboratory test results and symptoms, in combination with a recent DVT diagnosis, warranted a CT chest study to rule out PE. The study was positive, showing right segmental and subsegmental PE, even though the patient reported good compliance with apixaban. Neurological symptoms did not recur, and no leg swelling or weakness was evident after the initiation of the therapy.
The present study reports a unique presentation of DVT in the form of foot drop in a middle-aged man with an absence of known risk factors. Great emphasis should be placed on neurological causes when encountering a patient with unilateral limb weakness, but a compressive cause must also be considered.
DVT presentation varies significantly between patients; the usual presentation of DVT is unilateral leg swelling, pain, and warmth. However, subtle changes that are challenging to observe clinically can make diagnosis difficult. In one study of DVT , leg swelling was found to have a sensitivity of 97% and a specificity of 33%, whereas pain had a sensitivity of 86% and a specificity of 19%. In addition, the study found warmth to have a sensitivity of 72% and a specificity of 48%. These were the most common signs of DVT, and, as shown in that study, they were not very specific. Furthermore, DVT presentation is usually confined to 1 leg, but bilateral DVT can also be present. Other signs observed in DVT presentation include dilated superficial veins or tenderness over the calf muscles . Another sign reported is Homan’s sign, which is calf pain reproduced by ankle dorsiflexion, but it is also unreliable in the diagnosis of DVT. Other severe forms of DVT presentation are proximal DVT causing phlegmasia alba dolens, which is a swollen, painful, and pale or white limb, and phlegmasia cerulea dolens, which is a limb that is dusky or blue in color.
Unusual risk factors have been reported in the literature. Chandur et al reported on a patient who developed DVT a few days after taking a COVID vaccine . Another case report presented the story of a patient who had DVT, and a few weeks later, developed neurological symptoms. After investigations, he turned out to have a cobalamin deficiency . Our patient in this study presented with foot drop, and after initial investigations were negative, except for D-dimer, a POCUS was carried out by an experienced emergency medicine physician to exclude a compressive cause; in this case, thrombus, as arterial pulses were palpable. The POCUS showed non-compressible veins, which led us to order an official ultrasound, which confirmed thrombosed veins. The presentation of foot drop in our patient was therefore due to a compressive pathology along the deep peroneal nerve, the common peroneal nerve, or the sciatic nerve.
A compressive cause, although rare, must be excluded when encountering unilateral lower limb weakness without a neurologically clear cause. Therefore, POCUS is a valuable tool in the evaluation of acute unilateral lower limb weakness.
FiguresFigure 1.. Official ultrasound of the patient showing signs of DVT (noncompressibility) in the left external iliac veins. The arrow is pointing to the site of non-compressibility in the left external iliac vein. DVT, deep vein thrombosis. Figure 2.. Official ultrasound of the patient showing signs of DVT (noncompressibility) in the left superficial femoral veins. DVT, deep vein thrombosis. Figure 3.. Official ultrasound of the patient showing signs of DVT (noncompressibility) in the left common femoral veins. Power of magnification: 38 Hz; plane of view: transverse; method of staining: 2-dimensional gray scale; DVT, deep vein thrombosis.
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