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Ghulam H. Malika
Jamal S. Al-Wakeela
Suleiman Al-Mohayaa
Ibrahim Wasfb
MohammadS. Kechrida
Hazem H. El-Gamala
Abstract
A 23-year-old Saudi female presented with nephrotic syndrome. On renal biopsy she had primary focal and segmental glomerulosclerosis which was resistant to steroids. Two years later she presented with absent left arm pulses and on investigation a diagnosis of left ventricular thrombosis and thromboembolism of left brachial artery was made. Low antithrombin III, high fibrinogen levels and diuretic therapy were the possible causative factors for hypercoagulable state. On anticoagulation therapy initiated with heparin and continued with warfarin for 8 weeks there was complete dissolution of intraventricular and improvement of left brachial artery thrombosis. An early diagnosis and treatment of this potentially serious complication of nephrotic syndrome are stressed.
Key Words
Intraventricular thrombosis
Brachial artery thrombosis
Nephrotic syndrome
Hypercoagulable state
Introduction
Addis [ 1 ] in 1949 reported a high incidence of leg vein thrombosis in nephritis. Since then a number of reports have appeared highlighting the association of both venous and arterial thrombosis in patients with nephrotic syndrome [2-6]. Fishberg [7] drew general attention to the arterial thrombi for the first time. Whereas children show about an equal incidence of arterial and venous thrombosis [6], in adults arterial thrombosis is much less common than venous thrombosis [8]. Nolasco et al. [9] in a series of 89 adult minimal change nephrotics found that 11 had deep venous thrombosis whereas only 1 had arterial thrombosis of the femoral artery.
Though uncommon, almost every artery has been involved, together with intracardiac thrombi [8-11]. To the best of our knowledge, intraventricular and peripheral arterial thrombosis in the same patient has not been reported. We describe a case of nephrotic syndrome with left intraventricular and left brachial artery thrombosis.
Case Report
A 23-year-old Saudi female was admitted to the Nephrology Services in February 1994 for oliguria, facial puffiness and edema of the lower limbs of 2 months' duration. On physical examination the patient had: pulse 80/min, regular, BP = 150/115 mm Hg, facial puffiness and pedal edema. The rest of the clinical examination was unremarkable. Laboratory data: urinalysis showed proteinuria of 12.6 g/day and microscopically there were 15-30 RBCs, 4-6 WBCs with few granular casts/high-power field, hemoglobin 112 g/l, platelet count...