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Internal Jugular Vein Thrombosis due to Chronic Kidney Disease: A Case Report
Case Report Internal Jugular Vein Thrombosis due to Chronic Kidney Disease: A Case Report Hakan Kara, Giresun, Turkey
Internal jugular vein (IJV) thrombosis is a rare vascular event. The most common causes of internal jugular vein thrombosis are prolonged central venous catheterization, infection, malignancy and ovarian hyperstimulation syndrome. We have presented here a case of an 82-year-old male with chronic kidney disease who presented with left neck swelling and pain who was found to have a thrombus in the left IJV. He was successfully treated with conservative treatment without any complications.
Internal jugular vein (IJV) thrombosis is a rare condition that is underdiagnosed and associated with significant morbidity such as pulmonary embolism and post-thrombotic (postphlebitic) syndrome.1 Chronic kidney disease (CKD) is associated with increased risk for cardiovascular disease morbidity and mortality. The present article presents a case of IJV thrombosis diagnosed using venous Doppler ultrasonography in a patient with CKD, who had no malignancy, coagulation disorder, central venous catheterization, or any source of infection.
CASE REPORT An 82-year-old male patient administered to our department with a 2-day history of left-sided neck pain, swelling, shortness of breath, and weakness. He had no history of malignancy, central venous catheterization, or coagulation disorders. Physical examination revealed tenderness over the left side of the neck with palpable
Department of Cardiovascular Surgery, Giresun Ada Hospital, Giresun, Turkey. Correspondence to: Hakan Kara, MD, Department of Cardiovascular Surgery, Giresun Ada Hospital, Aydınlar Street G.M.K. Avenue, No: 248, Giresun, Turkey; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e3 https://doi.org/10.1016/j.avsg.2019.08.074 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: July 3, 2019; manuscript accepted: August 3, 2019; published online: - - -
swelling (Fig. 1). Apart from this, the otolaryngology examination was normal. He did not report any personal or family history of thrombophilia. Venous Doppler ultrasonography of the neck showed left IJV filled with high echogenicity (Fig. 2). His medical history revealed that he had insulin-dependent diabetes mellitus, hypertension, coronary artery disease, and CKD. The patient had been followed up for CKD for 4 years. His body temperature was 36.8 C, blood pressure was 140/90 mm Hg, and heart rate was 80 bpm. His electrocardiogram was normal sinus rhythm and V1eV4 pathological Q wave. His echocardiography revealed the following: ejection fraction 40%, ascending aorta diameter: 44 mm, mild aortic regurgitation, mildemoderate mitral regurgitation, apical septum and apex akinetic, pulmonary artery pressure 35 mm Hg, left ventricle diameters 38/57 mm, and interventricular septum 12 mm. Neck ultrasonography showed several reactive-appearing lymph nodes in cervical, submandibular, and parotid gland regions, the largest of which was 16 6 mm in the right cervical region. There was no abscess observed in the neck area. Furthermore, the laboratory tests revealed the following: white blood cell 8,270/mL, hemoglobin 10.8 g/dL, hematocrit 33.7%, platelet 172,000/mL, glucose 328 mg/dL, sodium 138 mEq/L, potassium 4.5 mEq/L, urea 42 mg/dL, creatinine 2.46 mg/dL, aspartate aminotransferase 12 IU/L, alanine transaminase 10 IU/L, C-reactive protein 3.68 mg/dL, and erythrocyte sedimentation rate 42 mm/hr. International normalized ratio 0.95, fibrinogen 262 mg/dL, partial thromboplastin time, and prothrombin time were normal. Work-up for thrombophilic disorders included homocysteine, protein C, protein S, antithrombin III, and anticardiolipin antibody levels
1.e1
1.e2 Case Report
Annals of Vascular Surgery
was given subcutaneous; intravenous ampicillin/sulbactam and analgesic drug were also administered. The patient was discharged on oral anticoagulant after 5 days without any complication. There was no reproduction in the culture of blood.
DISCUSSION
Fig. 1. Lateral view of the neck shows swelling of the IJV region (white arrow).
Fig. 2. Doppler ultrasonography of the neck shows a left internal jugular vein thrombus. which were all within the normal range. There were no abnormal findings on his chest X-ray. Computed tomographic (CT) scan of the abdomen showed bilateral renal cyst and left renal pelvis stone. CT scan of the thorax showed that there was no mass and mediastinal lymph node. Since our case was a patient with CKD, contrastenhanced CT was not performed. We used venous Doppler ultrasonography to diagnose IJV thrombosis in our patient. Low-molecular-weight heparin (LMWH)
IJV thrombosis is the formation of thrombus located intraluminally in the IJV and is 85% unilateral. It may be a secondary as a complication of head and neck infections, surgery and trauma, local skin infections, throat infections, local or distant malign tumor (Trousseau’s syndrome), central venous catheter placement, intravenous drug abuse, polycythemia, Lemierre’s syndrome, ovarian hyperstimulation syndrome, hypercoagulable state secondary to factor V Leiden, protein C, protein S, and antithrombin III deficiency, or it may be a primary IJV thrombosis.2 Lemierre syndrome is a rare complication of oropharyngeal or odontogenic infections generally occurring in young individuals, characterized by thrombophlebitis of IJV and sepsis caused by Gram-negative bacteria confirmed by blood culture for Fusobacterium necrophorum. Findings of a cross-sectional study suggested that the most common causes of IJV thrombosis are cancer and central venous catheter. In this study involving 29 cases, the causes of IJV thrombosis were found to be cancer, central venous catheter, and ovarian hyperstimulation syndrome in 23 cases, and primary IJV thrombosis in 6 cases.3 The IJV is a common route used by clinicians to access the central circulation for hemodynamical monitoring and treatment. A retrospective review by Major et al.4 showed that the presence of a central venous catheter was a significant factor for IJV thrombosis. In our case, there was no history of any central venous catheter intervention. Bilateral IJV thrombosis is extremely rare and can be an indicator of early malignancy.5 Bandara et al.6 reported that hidden malignancy should be investigated in patients with spontaneous IJV thrombosis. In a study conducted on IJV thrombosis involving 41 cases conducted by Hahn et al.,7 the cause was found to be malignancy in 22 (53.6%) patients, inflammatory diseases such as cervical abscess in 14 (34.1%) patients, and insertion of a central venous catheter in 2 (4.8%) patients, while no cause was identified in 3 (7.3%) patients. In our patient, we examined for malignancy in the entire body, but could not find any malignancy. CKD is defined as the occurrence of abnormalities of kidney structure or function, present for
Volume
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>3 months. CKD leads to the accumulation of uremic toxins, which exert toxic effects on blood and the vessel wall.8 The risk of venous thromboembolism is increased across the spectrum of CKD, including mild and more advanced CKD, nephrotic syndrome, end-stage renal disease, and after kidney transplant. This increased risk may be due to underlying hemostatic derangements, including activation of procoagulants, decreased endogenous anticoagulants, enhanced platelet activation and aggregation, and decreased fibrinolytic activity.9 Moderate decrease in kidney function (30 < estimated glomerular filtration rate [eGFR] < 60 mL/min/ 1.73 m2) and severe decrease in kidney function (eGFR < 30 mL/min/1.73 m2) are respectively associated with a 2.5-fold and a 5.5-fold increase in venous thrombosis risk.10 We suspected that the cause of his IJV thrombosis was a result of CKD. IJV thrombosis is asymptomatic in the majority of patients. However, the main symptoms were neck swelling, pain, or other clinical manifestations such as fever and weakness. Our patient had a 2day history of neck pain on the left side, swelling, shortness of breath, and weakness. Venous Doppler ultrasonography is the diagnostic tool for IJV thrombosis. Ultrasonographic findings include a dilated, incompressible vein and intraluminal clot. We used venous Doppler ultrasonography to diagnose IJV thrombosis in our patient. Contrastenhanced CT may be useful for diagnosing suspected IJV thrombosis. Since our patient had CKD, no contrast-enhanced CT was performed. Anticoagulants, fibrinolytics, and antibiotic drugs can be used to treat IJV thrombosis. Complications of IJV thrombosis are pulmonary embolism (10.3%) and post-thrombotic syndrome (41.4%).3 Sometimes a superior vena cava filter can be used to prevent pulmonary embolism. Mortality is significantly higher in patients with underlying comorbidities such as malignancy, CKD, infections, and multiorgan failure.2 We treated our patient with LMWH, ampicillin/sulbactam,
Case Report
1.e3
and analgesic drug without any complication or mortality.
CONCLUSIONS In conclusion, thrombosis of the IJV is a rare condition. It can be the first symptom of a malignant primary disease. Further investigations on malignancy, hypercoagulopathy, or infections are necessary for this disease. Furthermore, IJV thrombosis should be considered in patients with CKD in case of pain and swelling in the neck area. REFERENCES 1. Corral J, Villanueva G. A case study of deep vein thrombosis of the right internal jugular vein in a healthy 21-year-old male. Case Rep Hematol 2016;2016:7654749. 2. Lee Y, Siddiqui WJ. Internal Jugular Vein Thrombosis. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2019. 3. Gbaguidi X, Janvresse A, Benichou J, et al. Internal jugular vein thrombosis: outcome and risk factors. QJM 2011;104: 209e19. 4. Major KM, Bulic S, Rowe VL, et al. Internal jugular, subclavian, and axillary deep venous thrombosis and the risk of pulmonary embolism. Vascular 2008;16:73e9. 5. Leci-Tahiri L, Zherka-Saracini H, Tahiri A, et al. Bilateral internal jugular vein thrombosis due to malignant tumor. J Med Case Rep 2018;12:42. 6. Bandara AR, Wimalarathna H, Kalupahana R, et al. Internal jugular venous thrombosis due to Trousseau’s syndrome as the presenting feature of metastatic prostate carcinoma: a case report. J Med Case Rep 2016;10:104. 7. Hahn J, Nordmann-Kleiner M, Hoffmann TK, et al. Thrombosis of the internal jugular vein in the ENT-departmentd prevalence, causes and therapy: a retrospective analysis. Auris Nasus Larynx 2019;46:624e9. 8. Addi T, Dou L, Burtey S. Tryptophan-derived uremic toxins and thrombosis in chronic kidney disease. Toxins 2018;10. 9. Wattanakit K, Cushman M. Chronic kidney disease and venous thromboembolism: epidemiology and mechanisms. Curr Opin Pulm Med 2009;15:408e12. 10. Ocak G, Lijfering WM, Verduijn M, et al. Risk of venous thrombosis in patients with chronic kidney disease: identification of high-risk groups. J Thromb Haemost 2013;11: 627e33.
Internal jugular vein (IJV) thrombosis is a rare vascular event. The most common causes of internal jugular vein thrombosis are prolonged central venous catheterization, infection, malignancy and ovarian hyperstimulation syndrome. We have presented here a case of an 82-year-old male with chronic kidney disease who presented with left neck swelling and pain who was found to have a thrombus in the left IJV. He was successfully treated with conservative treatment without any complications.
Internal jugular vein (IJV) thrombosis is a rare condition that is underdiagnosed and associated with significant morbidity such as pulmonary embolism and post-thrombotic (postphlebitic) syndrome.1 Chronic kidney disease (CKD) is associated with increased risk for cardiovascular disease morbidity and mortality. The present article presents a case of IJV thrombosis diagnosed using venous Doppler ultrasonography in a patient with CKD, who had no malignancy, coagulation disorder, central venous catheterization, or any source of infection.
CASE REPORT An 82-year-old male patient administered to our department with a 2-day history of left-sided neck pain, swelling, shortness of breath, and weakness. He had no history of malignancy, central venous catheterization, or coagulation disorders. Physical examination revealed tenderness over the left side of the neck with palpable
Department of Cardiovascular Surgery, Giresun Ada Hospital, Giresun, Turkey. Correspondence to: Hakan Kara, MD, Department of Cardiovascular Surgery, Giresun Ada Hospital, Aydınlar Street G.M.K. Avenue, No: 248, Giresun, Turkey; E-mail: [email protected] Ann Vasc Surg 2019; -: 1.e1–1.e3 https://doi.org/10.1016/j.avsg.2019.08.074 Ó 2019 Elsevier Inc. All rights reserved. Manuscript received: July 3, 2019; manuscript accepted: August 3, 2019; published online: - - -
swelling (Fig. 1). Apart from this, the otolaryngology examination was normal. He did not report any personal or family history of thrombophilia. Venous Doppler ultrasonography of the neck showed left IJV filled with high echogenicity (Fig. 2). His medical history revealed that he had insulin-dependent diabetes mellitus, hypertension, coronary artery disease, and CKD. The patient had been followed up for CKD for 4 years. His body temperature was 36.8 C, blood pressure was 140/90 mm Hg, and heart rate was 80 bpm. His electrocardiogram was normal sinus rhythm and V1eV4 pathological Q wave. His echocardiography revealed the following: ejection fraction 40%, ascending aorta diameter: 44 mm, mild aortic regurgitation, mildemoderate mitral regurgitation, apical septum and apex akinetic, pulmonary artery pressure 35 mm Hg, left ventricle diameters 38/57 mm, and interventricular septum 12 mm. Neck ultrasonography showed several reactive-appearing lymph nodes in cervical, submandibular, and parotid gland regions, the largest of which was 16 6 mm in the right cervical region. There was no abscess observed in the neck area. Furthermore, the laboratory tests revealed the following: white blood cell 8,270/mL, hemoglobin 10.8 g/dL, hematocrit 33.7%, platelet 172,000/mL, glucose 328 mg/dL, sodium 138 mEq/L, potassium 4.5 mEq/L, urea 42 mg/dL, creatinine 2.46 mg/dL, aspartate aminotransferase 12 IU/L, alanine transaminase 10 IU/L, C-reactive protein 3.68 mg/dL, and erythrocyte sedimentation rate 42 mm/hr. International normalized ratio 0.95, fibrinogen 262 mg/dL, partial thromboplastin time, and prothrombin time were normal. Work-up for thrombophilic disorders included homocysteine, protein C, protein S, antithrombin III, and anticardiolipin antibody levels
1.e1
1.e2 Case Report
Annals of Vascular Surgery
was given subcutaneous; intravenous ampicillin/sulbactam and analgesic drug were also administered. The patient was discharged on oral anticoagulant after 5 days without any complication. There was no reproduction in the culture of blood.
DISCUSSION
Fig. 1. Lateral view of the neck shows swelling of the IJV region (white arrow).
Fig. 2. Doppler ultrasonography of the neck shows a left internal jugular vein thrombus. which were all within the normal range. There were no abnormal findings on his chest X-ray. Computed tomographic (CT) scan of the abdomen showed bilateral renal cyst and left renal pelvis stone. CT scan of the thorax showed that there was no mass and mediastinal lymph node. Since our case was a patient with CKD, contrastenhanced CT was not performed. We used venous Doppler ultrasonography to diagnose IJV thrombosis in our patient. Low-molecular-weight heparin (LMWH)
IJV thrombosis is the formation of thrombus located intraluminally in the IJV and is 85% unilateral. It may be a secondary as a complication of head and neck infections, surgery and trauma, local skin infections, throat infections, local or distant malign tumor (Trousseau’s syndrome), central venous catheter placement, intravenous drug abuse, polycythemia, Lemierre’s syndrome, ovarian hyperstimulation syndrome, hypercoagulable state secondary to factor V Leiden, protein C, protein S, and antithrombin III deficiency, or it may be a primary IJV thrombosis.2 Lemierre syndrome is a rare complication of oropharyngeal or odontogenic infections generally occurring in young individuals, characterized by thrombophlebitis of IJV and sepsis caused by Gram-negative bacteria confirmed by blood culture for Fusobacterium necrophorum. Findings of a cross-sectional study suggested that the most common causes of IJV thrombosis are cancer and central venous catheter. In this study involving 29 cases, the causes of IJV thrombosis were found to be cancer, central venous catheter, and ovarian hyperstimulation syndrome in 23 cases, and primary IJV thrombosis in 6 cases.3 The IJV is a common route used by clinicians to access the central circulation for hemodynamical monitoring and treatment. A retrospective review by Major et al.4 showed that the presence of a central venous catheter was a significant factor for IJV thrombosis. In our case, there was no history of any central venous catheter intervention. Bilateral IJV thrombosis is extremely rare and can be an indicator of early malignancy.5 Bandara et al.6 reported that hidden malignancy should be investigated in patients with spontaneous IJV thrombosis. In a study conducted on IJV thrombosis involving 41 cases conducted by Hahn et al.,7 the cause was found to be malignancy in 22 (53.6%) patients, inflammatory diseases such as cervical abscess in 14 (34.1%) patients, and insertion of a central venous catheter in 2 (4.8%) patients, while no cause was identified in 3 (7.3%) patients. In our patient, we examined for malignancy in the entire body, but could not find any malignancy. CKD is defined as the occurrence of abnormalities of kidney structure or function, present for
Volume
-, -
2019
>3 months. CKD leads to the accumulation of uremic toxins, which exert toxic effects on blood and the vessel wall.8 The risk of venous thromboembolism is increased across the spectrum of CKD, including mild and more advanced CKD, nephrotic syndrome, end-stage renal disease, and after kidney transplant. This increased risk may be due to underlying hemostatic derangements, including activation of procoagulants, decreased endogenous anticoagulants, enhanced platelet activation and aggregation, and decreased fibrinolytic activity.9 Moderate decrease in kidney function (30 < estimated glomerular filtration rate [eGFR] < 60 mL/min/ 1.73 m2) and severe decrease in kidney function (eGFR < 30 mL/min/1.73 m2) are respectively associated with a 2.5-fold and a 5.5-fold increase in venous thrombosis risk.10 We suspected that the cause of his IJV thrombosis was a result of CKD. IJV thrombosis is asymptomatic in the majority of patients. However, the main symptoms were neck swelling, pain, or other clinical manifestations such as fever and weakness. Our patient had a 2day history of neck pain on the left side, swelling, shortness of breath, and weakness. Venous Doppler ultrasonography is the diagnostic tool for IJV thrombosis. Ultrasonographic findings include a dilated, incompressible vein and intraluminal clot. We used venous Doppler ultrasonography to diagnose IJV thrombosis in our patient. Contrastenhanced CT may be useful for diagnosing suspected IJV thrombosis. Since our patient had CKD, no contrast-enhanced CT was performed. Anticoagulants, fibrinolytics, and antibiotic drugs can be used to treat IJV thrombosis. Complications of IJV thrombosis are pulmonary embolism (10.3%) and post-thrombotic syndrome (41.4%).3 Sometimes a superior vena cava filter can be used to prevent pulmonary embolism. Mortality is significantly higher in patients with underlying comorbidities such as malignancy, CKD, infections, and multiorgan failure.2 We treated our patient with LMWH, ampicillin/sulbactam,
Case Report
1.e3
and analgesic drug without any complication or mortality.
CONCLUSIONS In conclusion, thrombosis of the IJV is a rare condition. It can be the first symptom of a malignant primary disease. Further investigations on malignancy, hypercoagulopathy, or infections are necessary for this disease. Furthermore, IJV thrombosis should be considered in patients with CKD in case of pain and swelling in the neck area. REFERENCES 1. Corral J, Villanueva G. A case study of deep vein thrombosis of the right internal jugular vein in a healthy 21-year-old male. Case Rep Hematol 2016;2016:7654749. 2. Lee Y, Siddiqui WJ. Internal Jugular Vein Thrombosis. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2019. 3. Gbaguidi X, Janvresse A, Benichou J, et al. Internal jugular vein thrombosis: outcome and risk factors. QJM 2011;104: 209e19. 4. Major KM, Bulic S, Rowe VL, et al. Internal jugular, subclavian, and axillary deep venous thrombosis and the risk of pulmonary embolism. Vascular 2008;16:73e9. 5. Leci-Tahiri L, Zherka-Saracini H, Tahiri A, et al. Bilateral internal jugular vein thrombosis due to malignant tumor. J Med Case Rep 2018;12:42. 6. Bandara AR, Wimalarathna H, Kalupahana R, et al. Internal jugular venous thrombosis due to Trousseau’s syndrome as the presenting feature of metastatic prostate carcinoma: a case report. J Med Case Rep 2016;10:104. 7. Hahn J, Nordmann-Kleiner M, Hoffmann TK, et al. Thrombosis of the internal jugular vein in the ENT-departmentd prevalence, causes and therapy: a retrospective analysis. Auris Nasus Larynx 2019;46:624e9. 8. Addi T, Dou L, Burtey S. Tryptophan-derived uremic toxins and thrombosis in chronic kidney disease. Toxins 2018;10. 9. Wattanakit K, Cushman M. Chronic kidney disease and venous thromboembolism: epidemiology and mechanisms. Curr Opin Pulm Med 2009;15:408e12. 10. Ocak G, Lijfering WM, Verduijn M, et al. Risk of venous thrombosis in patients with chronic kidney disease: identification of high-risk groups. J Thromb Haemost 2013;11: 627e33.