JOURNAL OF ADOLESCENT HEALTH CARE 3:51-52, 1982

Deep Vein Thrombosis Unknown Etiology in a

and Pulmonary Embolism of 16-Year-Old Male

C H A R L E S C A R S O N , M.D. , ROBERT L. J O H N S O N , M . D . , PAULETTE S T A N F O R D , M . D . ,

J O C E L Y N E LOUIS- JACQUES, M . D . , E D W A R D M C M A N U S , B.A. , A N D

C H A R L E S V A N H O O K , B.A.

Deep vein thrombosis and pulmonary embolism is a di- agnosis that may be overlooked in the healthy adolescent even when presenting with typical symptoms. The fol- lowing case presentation highlights a number of the di- agnostic and therapeutic pitfalls that the clinician may encounter in an adolescent with pains in the chest and leg.

KEY WORDS:

Deep vein thrombosis Pulmonary embolism Chest pain

Thrombosis of the deep veins of the lower extremity and subsequent pu lmonary embolism are not un- common events in adults; ,especially when there are predisposing factors such as obesity, estrogen ther- apy, prolonged immobilization, malignancy, or ne- phrotic syndrome. Adolescents however are not im- mune to the occurrence of thrombosis whether it occurs spontaneously (1,2) or as a result of a pre- disposing factor. However, deep vein thrombosis (DVT) in a heal thy adolescent male As such an un- likely diagnosis that it may be overlooked.

From the University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Department of Pediatrics, Division of Adolescent Medicin e , 100 Bergen Street, Newark, New Jersey 07103.

Address reprint requests: Robert L. Johnson, M.DI University of Medicine & Dentistry of New Jersey, New Jersey Medical School, De- partment of Pediatrics, Division of Adolescent Medicine, 100 Bergen St., Newark, NJ 07103.

Manuscript accepted 30 March 1982.

Case Report

A 16-year-old black male presented to our adolescent clinic with a 2-day history of severe right inguinal pain. He stated that the pain began suddenly on the morning of the day of onset and progressively increased in intensity. He could neither walk nor change his trousers without assistance. There was no history of trauma or sexually transmitted disease. He said he had been healthy all his life except for a 3-day hospitalization one week prior. That admission was preceded by 2 days of right-sided chest and right upper quadrant abdominal pains. These symp- toms were accompanied by a cough, malaise, anorexia, and weight loss. He had diminished breath sounds on the right and right upper abdominal quadrant guarding. He was afebrile. X-rays of the chest and abdomen were neg- ative. His symptoms improved without specific therapy and he was discharged on the third hospital day. At the time of the present clinic visit, his chest and abdominal symptoms had resolved; however, he did complain of a nonproductive cough which he associated with smoking. He denied having the right inguinal pain during his hos- pitalization.

On physical examination, he was a slender, well-de- veloped black male. Vital signs were: temperature 100.4°F, pulse 96/min., respiration 24/min. and BP 130/90. Breath sounds were bilaterally equal. There was no abdominal tenderness. The right inguinum was swollen and tender but not hot. There were enlarged lymph nodes. The pa- tient could not flex his right leg at the hip. The right leg was not swollen below the inguinal area. He was admit- ted.

Initially, his symptoms responded to bed rest. Labo- ratory studies including liver function tests, blood and urine cultures, and gonococcal cultures were negative. He had no sickle hemoglobin. On the thir d hospital day, his right leg was swollen and tender measuring 4-5 cm larger

© Society for Adolescent Medicine, 1982 51 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017 0197-0070/82/010051 +02502.75

52 CARSON ET AL. JOURNAL OF ADOLESCENT HEALTH CARE Vol. 3, No. 1

in diameter than the left. A right femoral venogram re- vealed extensive thrombosis of the deep veins of the right calf with absence of filling of the deep veins of the thigh. A ventil!ation perfusion scan was compatible with mul- tiple pulmonary emboti in the left and right lower lobes. This finding was confirmed with an arteriogram.

He was treated with intravenous streptokinase for four days followed by a heparin infusion for six days. Oral Coumadin was added and continued for the remainder of the hospital stay. Over the hospital course the pai n and swelling gradually subsided.

Several avenues were investigated to establish an etiol- ogy: an intravenous pyleogram, upper gastrointestinal, and small bowel x-ray series and abdominal and pelvic ultrasound were performed in search of an occult malig- nancy, but none was demonstrated. His family history revealed a 15-year-old sister who had a blood clot in her left leg (she was not on oral contraceptives ) and his father died during surgery for a fracture of the right ankle. The stated cause was pulmonary embolism. Three of his moth- er's pregnancies ended in still birth. This family history is compatible with antithrombin II! deficiency (3-4) but the patient's level was slightly elevated (32/xg%, n-- 17- 30/xg%) and was not depressed in those family members available for testing.

A repeat venogram on the 20th hospital day showed continued poor filling of the deep veins of the right calf and thigh with numerous superficial collaterals. Because of his progressive clinical improvement, he was dis- charged on the 30th hospital day.

Discussion Al though increasing in f requency, deep vein th rom- bosis is still a rare event in the adolescent (1,6). This is part icularly true in the absence of p red i spos ing factors. The diagnosis becomes even more elusive sinc e m a n y of the usual p resen t ing signs and symp- toms of DVT are not u n c o m m o n to the physical ly active adolescent .

It is reasonable to a s s um e that the pat ient in our

case h is tory had an a symptoma t i c th rombos is in his deep veins at the t ime of his first hospital izat ion. His p resen t ing s y m p t o m s were probably the result of p u l m o n a r y embol iza t ion f rom that th rombus . It has been well es tabl ished that the classical s y m p - toms (cough, dyspnea , and chest pain) are unreli- able clues in the diagnosis of p u l m o n a r y embol i sm (7,8). This is part icularly true w h e n the pat ient has no o ther complaints ; there are other c o m m o n rea- sons for the s y m p t o m s (i.e., viral syndrome) ; and the s y m p t o m s improve wi th bed rest.

In s u m m a r y , this case demons t r a t e s that deep vein th rombos i s can occur in an apparen t ly other- wise hea l thy adolescent wi thou t k n o w n pred ispos - ing factors. The clinician should be alert to the pos- sible diagnosis of this occasionally subtle but potent ia l ly fatal condit ion.

References 1. Horwitz J, Shenker IR: Spontaneous deep vein thrombosis

in adolescence. Clin Pediatr 16:787-790, 1977 2. Wise RC, Todd JK: Spontaneous lower-extremity venous

thrombosis in children. Am J Dis Child 126:766-769, 1973 3. deBoer AC, vanRiel LAM, Ottolander GJH: Measurement of

antithrombin III a 2 macroglobulin and a 1 antitrypsin in patients with deep vein thrombosis and pulmonary embo- lism. Thromb Res 15:17-25, 1979

4. Johansson L, Hedner U, Nilsson IM: Familial antithrombin III as pathogenesis for deep vein thrombosis. Acta Med Scand 204(6):491-495, 1978

5. Marciniak E, Farley CH, DeSimone PA: Familial thrombosis due to antithrombin III deficiency. Blood 43:219-231, 1974

6. Machbur B, Baumgartner G, Huser J: Deep thrombophlebitis of the lower extremities in children. Vasa 8(1):53-59, 1959

7. Stein PD, Willis III PW, DeMets DL: History and physical examination in acute pulmonary embolism in patients with- out pre-existing cardiac or pulmonary disease. Am J Cardiol 47:218-223, 1981

8. Biello DR, Mattar AG, McKnight RC, et al.: Ventilation-per- fusion studies in suspected pulmonary embolism. Amer J Radio! 133(6):1033-1037, 1979