Dermatology Online Journal

Letter: An Unusual Giant Thrombus Displaying Percutaneous Elimination
Paulo Ricardo Criado MD PhD, Ricardo Romiti MD PhD, Ilana Halpern MD, Hebert Roberto Clivati Brandt MD
Dermatology Online Journal 17 (2): 14

Sao Paulo University, Dermatology Department, Sao Paulo, Brazil. prcriado@uol.com.br

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Abstract

We describe a female patient with a giant venous thrombus that exhibited transcutaneous elimination. This thrombus elimination is probably a unique case in the medical literature.

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Figure 1	Figure 2
Figure 1. Giant nodule on the left thigh; note that the nodule acquired aspect of an egg in a cup. Figure 2. Cutaneous histopathology revealed a large caliber vein with its original lumen partially filled with fibrin and enmeshed red cells (thrombus) (H&E, x100).

A 48-year-old healthy woman presented with a 6-week history of a giant inflammatory nodule affecting her left thigh. On physical examination, a hard black nodule measuring 10 cm in diameter was noted. It was lined by a firm stretched margin of erythematous skin, giving the tumor the aspect of an egg in a cup (Figure 1).

Differential diagnoses included melanoma, atypical fibroxantoma, dermatofibrosarcoma protuberans, and skin metastasis. The patient denied use of medications, previous surgeries, or prolonged imobility. Color-flow doppler ultrasonography revealed blood clots in the leg veins under the nodule and confirmed the presence of venous reflux into the superficial and deep vessels of legs and thighs.

Work-up for active malignancies proved negative. Anticardiolipin antibodies (IgM and IgG), lupus anticoagulant, Factor V (Leiden) mutation, prothrombin gene mutation, homocystein levels, protein S and C levels, antithrombin, fibrinogen, and cryoglobulin levels were negative or within the normal range. Surgical excision of the whole lesion was successful and complete recovery was observed. The histopathologic skin sections revealed a large caliber vein with its original lumen partially filled with fibrin and enmeshed red cells (thrombus) (Figure 2).

The term superficial vein thrombosis (SVT) is used when a thrombus is found by diagnostic testing such as compression ultrasonography or phlebography [1]. Predisposing risk factors for SVT are very similar to those for deep venous thrombosis (DVT) [1]. These include postoperative states, pregnancy, active malignancies, autoimmune diseases, use of oral contraceptives, previous venous thromboembolism, and varicose veins. In addition, the factor V Leiden (G1691A) and prothrombin mutation (20210A) as well as deficiencies of the natural anticoagulant proteins C and S are also diagnosed more often in patients with SVT than in healthy individuals, further strengthening the hypothesis that SVT and Venous Thromboembolism (VTE) have a comparable etiology [1]. Some authors have demonstrated that SVT can be associated with asymptomatic DVT, both in the same leg or in the contralateral leg [2].

In the present case, the only identifiable risk factor for thrombosis was the presence of varicose veins. The cause of the acute percutaneous elimination of the thrombus is unknown, although it might be speculated that localized vascular wall weakness or anatomical vascular alterations might have been present preceding the extrusion of the nodule.

We are unable to locate any similar cases in the medical literature, indexed in PubMed (Medline). This exuberant thrombus elimination probably is a unique case.

References

1. Ho WK. Deep vein thrombosis - risks and diagnosis. Am Fam Physicians 2010;39(2):468-74.

2. Binder B, Lackner HK, Salmhofer W, Kroemer S, Custovic J, Hofmann-Wellenhof R. Association between superficial vein thrombosis and deep vein thrombosis of the lower extremities. Arch Dermatol. 2009;145(7):753-7. [PubMed]

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