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Inferior vena cava thrombosis(IVCT) is relatively rare but life-threatening complications of sepsis and difficult to diagnose at early terms. To report the early diagnosis and successful medical treatment of a IVCT due to sepsis without anticoagulation in emergency department(ED).
A 32-year-old female patient was admitted to ED with fever, vomiting and diarrhea for 12 hours. Her past medical history was unremarkable and non-immunocompromised disease. A general physical examination has no obvious abnormity. On admission, BP was 68/39 mmHg and HR was 119 bpm. The results of determination showed: WBC 1.18×10ˆ9/L, PLT 90×10ˆ9/L; PCT 43.07ng/ml, Lac 4.4mmol/L, Cr 139umol/L; ALT 45U/L, AST 71U/L, ALB 23g/L, TBIL 18.7umol/L; PT 18.3s, INR 1.56, Fbg 1.64g/L, Pro-BNP 13535.0pg/ml, plasma D-dimer values was 12.90mg/L FEU. The diagnosis of severe sepsis was highly suspected. Over the next 6 hours, fluid resuscitation, hemodynamic support, antibiotic therapy and immunoglobin therapy were administered, but she also decompensated and went into refractory shock. In order to detect a possible infective source of the sepsis, The contrast enhanced CT scans of the chest and abdomen was arranged immediately, which demonstrated thrombosis of inferior vena cava and total occlusion below the origin of the renal veins and extending into bilateral common iliac vein.
The patient was transferred to EICU for further treatment. Her hemodynamics was gradually stabilizing by fluid resuscitation from upper extremity. She was treated for prolonged periods with antibiotics. Anticoagulation therapy was never administered because of coagulation disorder. Complete resolution of IVC thrombus was documented on reexamination of Contrast-enhanced CT scans after 11 days. The patient was discharged and followed up after 5 months, She improved with no further admission with the same complaints.
It remains great challenging for clinician to make an accurate diagnosis of IVCT at the early stage in sepsis because of the lacking of characteristic clinical manifestations. Sepsis is associated with complex procoagulant and anticoagulant changes that modify inflammatory response, which may through cross signaling results in immunothrombosis. In this case, IVCT may be an immune response in the local activation of coagulation facilitates the recognition and destruction of pathogens. In acute IVCT, sudden fall in venous return contributes to hemodynamic deterioration, resulting in life-threatening condition as refractory shock. IVCT is occurring autolysis after improvement of sepsis without anticoagulation therapy in this patient. According to a recently described new theory, patients may benefit from modulation of the coagulation system when systemic inflammation and hypercoagulopathy exist in sepsis.