Case Study

Deep Vein Thrombosis in Tuberculosis

Santosh Ghai*, Ritin Mohindra*, Neelima Jain**
Abstract
Pulmonary tuberculosis is very prevalent in developing countries but its thrombogenic
potential is a new entity. There are a few reports stating the relation of deep vein thrombosis
(DVT) with pulmonary tuberculosis (PTB). We are presenting a case series of three patients
with different forms of tuberculosis presenting with DVT having no risk factor for
hypercoagulability. We are highlighting an under-reported phenomenon so that high
suspicion, adequate prophylaxis and prompt management of DVT can play a vital role in the
survival of this subset of patients.

Keywords: Pulmonary tuberculosis, Deep vein thrombosis.

Introduction
India accounts for almost one-third of the global burden
of tuberculosis.1 Although the epidemiology and natural
history of the disease have been extensively described,
a hypercoagulable state has not been emphasized.
Tuberculosis continues to remain challenging with a
variety of clinical presentations of which systemic
hematological complications, like disseminated intra-
vascular coagulation (DIC) and deep vein thrombosis,
are quite rare.2,3 DVT is clinically observed and can be
confirmed with laboratory methods in 3-4% of patients
with pulmonary tuberculosis related to hypercoagulable
state secondary to the inflammatory state. The real
incidence may be closer to 10% because most of the
patients are thought to be clinically in-apparent.4 The
lack of awareness regarding the association is possibly
responsible for the condition not being recognized, and
hence, screening and treatment strategies have not
been standardized.
clinical signs suggestive of DVT were present. Color
venous Doppler of the lower limb showed echogenic
lumen in common femoral vein, saphenofemoral vein
and popliteal vein. The lesion showed absence of distal
compressibility. Venous system of the right leg was
normal. Routine investigations revealed anemia 9 g/dL
with thrombocytosis 5.03 lakh/mm3, and an increased
ESR 73 mm/hr. Her detailed coagulation profile was sent
for and was found to be deranged: D-Dimer 841(0–360),
FDP >300 mg/mL, PT 11.85 sec, INR 0.98, and aPTT 22.1
sec. The patient was started on LMWH and overlapped
with warfarin on fifth day. The patient showed
improvement in pain and swelling after 6 days of
anticoagulant therapy. She was discharged on 4-drug
ATT and oral anticoagulants with a target INR 2.0–3.0.
The patient was subsequently lost to follow-up.
Case Number Two

Case Report A 25-year-old male smoker and occasional alcoholic a

k/c/o old treated PTB diagnosed two and a half years,
Case Number One presented with complaints of intermittent low-grade
fever with evening rise of temperature for 6–7 months,
A 16-year-old unmarried female diagnosed to have minimal non-productive cough associated with
sputum positive pulmonary tuberculosis 10 days back exertional dyspnea for 3–4 months. There was no
presented to us with the complaints of painful left lower history of hemoptysis. He had now developed painful
limb swelling for the past 7 days. The patient was swelling of his lower limbs left>right for 6–7 days. There
already on 4-drug anti-tubercular treatment at was no history of prolonged immobilization, long travel
presentation. There was no history of long journey, or recent surgery or history suggestive of connective
trauma or recent surgery. She was a non-smoker or tissue disease. Examination revealed a poorly built,
alcoholic. On examination the swelling was tender and malnourished male with stable vitals.
*
Senior Resident, Department of Medicine, Unit 3A, VMMC and Safdarjung Hospital.
**
Professor, Department of Medicine, Unit 3A, VMMC and Safdarjung Hospital.
Correspondence to: Dr Santosh Ghai, Department of Medicine, Unit 3A, VMMC and Safdarjung Hospital.
E-mail Id: santosh_ghai@yahoo.com

© ADR Journals 2015. All Rights Reserved.

J. Adv. Res. Med. 2015; 2(3)
Respiratory examination was notable for the presence
of coarse crepitations in bilateral basal regions. There
was bilateral pedal edema extending from inguinal
region. Signs for DVT were positive in both legs. His
venous Doppler revealed extensive echogenic thrombus
extending from IVC to bifurcation distal to bilateral
popliteal veins. Investigations revealed a hemoglobin
level of 10.1 g/dL, total leukocyte count 13,500/mm3,
differential-polymorphs 87%, lymphocytes 10%, and
platelets 231,000/mm3. Peripheral blood smear was
normal. Renal and liver function tests were normal.
Coagulation profile was abnormal: D-Dimer was >4
mcg/mL, PT 10.7, INR 0.97, APTT 20.7 sec. ABG revealed
hypoxia. Chest radiograph revealed cavity in left upper
zone and extensive infiltration in right lung. Computed
tomography (CT) of the chest revealed nodular opacities
in both the lungs and cavitory lesions in left upper lobe
with necrotic lymph nodes. Patient was started on
empirical parenteral third-generation cephalosporin,
along with LMW heparin while sputum reports were
awaited. Meanwhile, sputum for acid-fast bacilli was
positive, and the patient was started on CAT-2 5-drug
ATT daily regimen as per body weight and overlapped
with warfarin with target INR of 2–3. Patient responded
well and was discharged after 10 days to follow up in
medicine OPD.
Case Number Three
A 25-year-old female presented with c/o low grade
fever on and off for the last 3 months associated with
breathlessness for 15 days. She was evaluated and
diagnosed to have pulmonary TB and started on ATT
which she stopped by herself after taking the drugs for
15 days. She had now developed swelling and redness
of her left lower limb along with pain and now
presented to our hospital. She was mobile and there
was no history of trauma, long travel or prolonged
immobilization.
Examination revealed diffuse crepitations all over chest
and swelling and tenderness of the thigh region of left
lower limb. Signs of DVT were positive. Investigations
done showed mild anemia with hypoalbuminemia with
normal remaining blood profile. D-Dimer was elevated.
Imaging tests-USG abdomen-revealed multiple
mesenteric lymphadenopathy and features s/o cystitis.
USG Doppler showed significant thrombus and non-
compressibility in left CFV, SFV, popliteal and posterior
tibial veins up to mid-calf region sparing distal calf along
with extension of thrombus into the external iliac vein,
common iliac up to inferior vena cava. CECT chest
showed consolidation with cavitation and bronchiectatic
changes in right upper, middle and superior segment of
5 ISSN: 2349-7181
Ghai S et al.
lower lobe, and bronchiectatic changes in left upper
lobe and necrotic conglomerate nodes in subcarinal
region. There was no evidence of pulmonary embolism.
CECT abdomen showed left femoral vein, external iliac,
common iliac vein not opacified with filling defect
extending to IVC proximally till the level of right renal
vein, and bilateral renal veins normal in caliber and
opacification. Patient was started on CAT 1 ATT under
DOTS regimen along with enoxaparin. She was
overlapped with acitrom till therapeutic INR was
reached. Patient was discharged after 2 weeks, as she
responded to the treatment with improvement in her
breathlessness and lower limb swelling, to follow up in
medicine OPD.
Discussion
Pulmonary tuberculosis is one of the most prevalent
diseases in our country. If advanced, its complications
are vast to counteract. However, hemostatic
complications are very rare and thrombogenic potential
of tuberculosis is not frequently documented in
literature but can have serious consequences. Reports
demonstrate the association between inflammation and
hemostatic changes arising in PTB that could result in a
hypercoagulable state which might predispose to
thrombotic phenomena. It not only involves venous
thromboembolism but thrombosis also in hepatic veins,
the vena porta, the inferior vena cava, cerebral venous
sinuses, and the central retinal vein. Disseminated TB
may induce at the peripheral blood the activation of
mononuclear cells, which interact with mycobacterial
products inducing increased synthesis of factor tumor
necrosis alpha and interleukin-6.5 Various studies have
concluded that the high level of plasma fibrinogen,
impaired fibrinolysis associated with a decrease in
antithrombin III, protein C and platelet aggregation
appear to induce a hypercoagulable state promoting the
development of deep vein thrombosis in pulmonary
tuberculosis.6 Some authors have mentioned the high
incidence of antiphospholipid antibodies and
hypoprothrombinemia in appreciable number of cases.
Cytokines by their pro-inflammatory character will
activate the vascular intima and make thrombogenic
endothelium. They will also lead to a stimulation of
hepatic synthesis of coagulation proteins.5 These risks of
hypercoagulability are increased by immobility and bed
rest because of the morbidity caused by the disease.
These hemostatic changes improve during the first
month of TB treatment and for this reason, it should be
immediately started in addition to anticoagulant
therapy.
Ghai S et al.
Conclusion
In our study, association between DVT and pulmonary
tuberculosis is plausible as the patients were young with
no specific risk factors for DVT; other causes for DVT
were ruled out systematically.
Our case report highlights the risk of deep vein
thrombosis developing in patients with severe
pulmonary tuberculosis even in the absence of specific
risk factors. We emphasize the potential seriousness of
this under-reported phenomenon, need for establishing
an early diagnosis, and institution of prompt treatment
for deep vein thrombosis while continuing the anti-
tuberculosis treatment. Thromboembolic disease is to
search systematically at the TB view of the risk of
occurrence of this complication particularly in extensive
and severe forms. Prophylactic anticoagulation finds its
indications in these forms.
Source(s) of Support: Nil
Conflict of Interest: Nil
ISSN: 2349-7181
J. Adv. Res. Med. 2015; 2(3)
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