Massive deep venous thrombosis in a patient addicted to cocaine

Losno, Ricardo A.; Milisenda, José C.; Aibar, Jesús

doi:10.1016/j.medcli.2019.02.009

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Losno, José C. Milisenda, Jesús Aibar" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Ricardo A." "apellidos" => "Losno" "email" => array:2 [ 0 => "ralosno@clinic.cat" 1 => "losnoric@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "José C." "apellidos" => "Milisenda" ] 2 => array:2 [ "nombre" => "Jesús" "apellidos" => "Aibar" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Clinic, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trombosis venosa profunda masiva en un paciente adicto a la cocaína" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1102 "Ancho" => 1500 "Tamanyo" => 174599 ] ] "descripcion" => array:1 [ "en" => "CT scan images. (A) Axial Image of the infrahepatic inferior vena cava (IVC) thrombosis (orange arrow). (B) Coronal Image of the infrahepatic IVC thrombosis (orange arrows). (C) Axial Image of both common iliacs thrombosis (orange arrows). (D) Axial Image of both femoral veins’ thrombosis (orange arrows)." ] ] ] "textoCompleto" => "Cocaine has become one of the most widely used illicit drugs among the Spanish population, leading to an increase in visits to the emergency department. The release of catecholamines in the context of cocaine can lead to deep hypertension, intense vasoconstriction and platelet activation which promotes thrombotic events such as myocardial infarction and stroke.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> In addition, cases of peripheral arterial thrombosis with involvement of the iliac, popliteal and distal arteries have been identified,<a class="elsevierStyleCrossRef" href="#bib0035">2</a> while the practice of injecting drugs through the femoral vein is associated with iliofemoral deep venous thrombosis (DVT).<a class="elsevierStyleCrossRef" href="#bib0040">3</a>We present a case of a 42-year-old man without allergies, active smoker, regular inhaled cocaine user and a past medical history of Hepatitis C Virus (HCV) infection without treatment. The patient was admitted to the Internal Medicine ward due to the presence of purpuric lesions and edemas in the lower extremities. On this admission, he admitted to taking cocaine the days prior to the onset of the complains. He was afebrile and haemodynamically stable. In the physical exploration the presence of edemas was corroborated in both lower extremities up to the groin with pitting edema and collateral circulation, without signs of necrosis and with present peripheral pulses.The blood test showed a leukocytosis of 24×109/L with 83% neutrophils, C-reactive protein 1.5mg/dl, alanine transaminase (ALT) 4 UI/L, aspartate transaminase (AST) 15 UI/L, gamma-glutamyl transferase (GGT) 28 UI/L, lactate dehydrogenase (LDH) 587 UI/L. Human immunodeficiency virus (HIV) negative. RNA HCV<15IU/mL. Cryoglobulins negative. An ultrasound showed bilateral iliac thrombosis affecting up to popliteal vessels. In view of these findings, a CT scan was performed which showed complete thrombosis of both common femoral veins, external iliacs, internal iliacs, common iliacs and the infrahepatic inferior vena cava (IVC) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with extension to both segmental renal veins and cavernomatous transformation of the hepatic IVC without signs of pulmonary thromboembolism. Finally, it has been performed a PET-CT that showed no alterations in the pattern of FDG uptake discarding malignancy.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>As triggering causes of DVT, the patient had not made long trips, recent surgery, nor was on any medication; a vasculitis HCV-associated was considered, but the viral load was less of 15IU/mL and cryoglobulins were negative. Subcutaneous enoxaparin 1mg/kg/12h was initiated. Thrombectomy was rejected due to the risk of complications and the impossibility of catheter passage due to the extension of the thrombosis. Six months after discharge, a blood study of thrombophilia was performed, which turned out to be negative. The patient showed a favorable evolution with great improvement of the signs of DVT and mobility.There are no previous cases of massive thrombosis due to inhaled cocaine, so a casual association cannot be ruled out, however the Naranjo causality algorithm was applied with a total score of 5 points (2 points for temporality, 2 points for no other causes, 1 point for drug been detected in urine). It was oriented as a probable adverse reaction to the use of inhaled cocaine. Acute arterial thrombosis is described as a complication of inhaled cocaine intake, while the practice of injecting drugs through the femoral vein is associated with iliofemoral DVT.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> However, cases of massive DVT secondary to inhaled cocaine are not reported. The mechanism by which cocaine can induce thrombosis is unknown. Heesch et al. demonstrated that exposure to cocaine causes platelet activation, release of granules and formation of platelet microaggregates.<a class="elsevierStyleCrossRef" href="#bib0050">5</a>We describe the case of a man with a history of sporadic use of inhaled cocaine who presented a massive DVT. Having reasonably ruled out other causes of DVT, we believe that the triggering cause could be the use of inhaled cocaine. As a provoked DVT, it was agreed to initiate and maintain anticoagulation for 6 months, with good clinical response afterwards." 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(D) Axial Image of both femoral veins’ thrombosis (orange arrows)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trastornos por cocaína e infarto agudo de miocardio, prolongación de estancias y exceso de costes hospitalarios" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Gili" 1 => "G. Ramírez" 2 => "L. Béjar" 3 => "J. López" 4 => "D. Franco" 5 => "J. 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