Title : Venous thromboembolism in a patient with vitamin B12 deficiency and probable Apla syndrome
Abstract:
Deep vein thrombosis (DVT) is a major preventable cause of morbidity and mortality. While early recognition of the condition is important, equally important is the identification of possible etiological factors. Each patient with venous thrombosis would have multiple factors responsible for venous thrombosis. Hence a holistic approach in the form of detailed history, including dietary history, adequacy of hydration, immobilization, travel, prolonged unusual postures and physical examination and necessary investigations are needed to solve the clinical problem.
A 41 year old lady who was apparently normal before the onset of symptoms presented with 2 weeks history of insidious onset progressive right lower limb oedema and pain mainly confined to the leg and dorsum of foot not associated with fever. Two days after she was admitted for evaluation, she developed sudden onset breathlessness as well after walking a few steps. She was a pure vegetarian and her dietary history suggested poor intake of fruits and green leafy vegetables as well. She also gave a history of tingling sensation of her lower limbs for the past few years. As far as her obstetric history was concerned, she had one spontaneous abortion in first trimester of her pregnancy at the age of 20. Her next two pregnancies were uneventful. On examination she was tachypneic, pale and her right lower leg was swollen and tender with no local rise in temperature or redness. Neurological examination was normal except for absent ankle jerk. Hence the provisional diagnosis was deep vein thrombosis with possible pulmonary venous thromboembolism with an underlying vitamin B12 deficiency (because of anaemia, strict vegetarian diet and absent ankle jerk). Since the patient gave a history suggestive of a recurrent pulmonary embolism and a history of spontaneous first trimester abortion an additional possibility of APLA syndrome was also considered. Ultrasound scan confirmed the diagnosis of DVT. Hence she was commenced on anticoagulation.
Her blood investigations showed that she had macrocytic anaemia, low B12 levels , prolonged APTT and reactive VDRL. However antiphospholipid antibody profile was negative. Therefore she was commenced on B12 supplementation as well along with lifelong anticoagulation.
Audience Takeaway:
- Vitamin B-12 deficiency is a well-recognized cause of hyper-homocysteinemia and the latter is a well-recognized cause of thrombosis
- Always look for multiple risk factors in a case of unprovoked thrombosis.
- Treated all the underlying reversible factors along with commencing anticoagulation in venous thrombosis.
