DVT (Deep Vein Thrombosis) Patient Case Study
Mrs Jane G-X, aged 54, an actress, complained of sudden, severe pain in her left leg, initially in the calf muscle, but later spreading up the leg.
At first the diagnosis was uncertain, but a day or so later the leg became swollen and more painful. Walking became impossible and the patient was confined to bed.
She was seen in casualty. The leg pain was made worse by gently pushing the front of the foot upwards.
A diagnosis of deep vein thrombosis (DVT) was made, confirmed by venogram, which showed a clot extending up above the knee. The patient was started on anti- clotting drugs - first heparin, and later warfarin.
Other tests showed a normal chest x-ray, important to initially locate any other cause for a clot including infection or a tumour, raised blood 'D-Dimer', which can indicate clotting and (a few days later) a positive lupus anticoagulant test.
What is this patient teaching us?
Leg blood clots are a common medical emergency. Commonly they are thought to be triggered by outside influences, such as immobility (long flights and other distance travel), drugs especially the combined oral contraceptive or following surgery, for example.
However, very often they arrive without any clear warning or cause. Mrs G-X had none of the “normal” precipitating factors. But she did have one important risk factor - the positive "lupus anticoagulant" test.
Lupus Anticoagulant is one of the markers for Hughes Syndrome ("sticky blood") and a real risk for DVT - some studies have shown that up to 1 in 5 of all cases of DVT have Hughes Syndrome. It is a somewhat confusing name for a test because it is not a test for lupus, but for sticky blood. The blood tests for Hughes Syndrome/Antiphospholipid Syndrome will be discussed in a future chapter and can be found in our Patient Information Leaflets on our website.
Of course there are other known risk factors for clotting, but Hughes Syndrome/APS is uniquely important. Why? Because most other clotting problems cause either vein OR artery clots but Hughes Syndrome/APS can lead to both artery clots (e.g. heart attack, stroke) as well as vein clots (such as DSVT or Pulmonary Embolus).
As always, taking the patient's full history was critical. She had 2 sisters, one with lupus and one with Hughes Syndrome (APS).
Years earlier, Mrs G-X had suffered severe, frequent migraines (a feature of the syndrome) and, indeed, a brain MRI some 10 years earlier had shown a number of 'dots', thought to have been mini brain clots.
The treatment? Warfarin anticoagulation is usually given for 6 months in a "straight- forward" DVT. However, in Mrs G-X's case, more prolonged - possibly lifelong - anticoagulant treatment is likely to be the safest way forward as the lupus anticoagulant may be associated with recurrent clots. Indeed because of the risk of recurrence, Warfarin is normally preferred to newer anticoagulants which in some studies have been associated with a greater risk of recurrence of blood clots in high risk patients so are still not widely used in Hughes Syndrome/APS