Volume 2 - Issue 8
Department of Pediatrics, Kauvery Hospital, Trichy, India
Deep vein thrombosis (DVT) is rare presentation in paediatric age group. DVT as a cause of leg pain in children is often misdiagnosed, because the index of suspicion is low in children. The incidence of venous thrombo embolism increases with age, from 0.7 to 2 per 100000 in children to 100 to 150 per 100000 in adults. We present such a case where in hindsight, clinical clues correlated with investigations.
A 14-year-old adolescent girl was brought to our emergency room in wheel chair with complaints of pain over the left groin for one week which gradually worsened affecting her mobility and fever for five days. She also developed swelling over the left groin for one day. There was no history of trauma, chronic cough, gastrointestinal symptoms, no familial history of thrombosis. She attained menarche one year back. Her physical examination revealed pallor and tender, warm swelling over left inguinal region, localised oedema with fixed flexion deformity of the left hip. Psoas abscess was suspected. USG lower limb revealed DVT involving left External Iliac vein and femoropopliteal system, confirmed by a doppler study.
Blood counts showed severe anaemia with thrombocytosis. RT-PCR for COVID-19 was negative. COVID IgG antibody was borderline positive. On further evaluation, serum ferritin was normal; CRP and D-dimer were elevated. Serum folic acid and vitamin B12 levels were low; homocysteine level was normal.
MRI pelvis with both hips revealed extensive DVT with altered signal intensity in left iliopsoas and extensive subcutaneous oedema.
IV antibiotics were given to cover Staphylococcal infection. Anaemia was corrected with two units of packed red cell transfusion and vitamin supplements were added.
After discussing with a team of Vascular surgeon, Paediatric hemato oncologist and Orthopaedician, it was decided to give anticoagulants for six months. She continued to have high grade fever spikes, but blood culture was sterile. IV antibiotics were continued.
Her general condition improved, pain and swelling reduced and she was able to extend her left leg. She was spared the scalpel as there was clinical improvement and a reduction in inflammatory markers. She was discharged on oral antibiotics and anticoagulant.
On review, Psoas abscess should not cause oedema and DVT should not produce a fixed flexion deformity. Infection associated DVT is the likely possibility here than iron deficiency anaemia and thrombocytosis being the cause. Deep vein thrombosis though rare in children is identified more often because of advances in skill and technology in imaging. It's incidence peaks in infants and in adolescents. Common causes encountered are central venous catheters, trauma, infection, prolonged immobilisation, major surgery, dehydration, nephrotic syndrome and rare iron deficiency anaemia, protein C, protein S deficiency .
Iron deficiency causing venous thromboembolism though rare, should be considered as it is an avoidable cause. Iron deficiency induced thrombocytosis poses a great risk in developing both arterial and venous thrombosis .
Dr. D. Suresh Chelliah
Senior Consultant Paediatrician (Head - Academics)