Respiratory physiotherapy in patients with Cystic Fibrosis and upper limb deep vein thrombosis

We report physiotherapy management of two patients with severe cystic fibrosis (CF) lung disease and upper limb deep vein thrombosis (DVT). These patients were admitted due to a pulmonary exacerbation. Following peripherally inserted central catheters they were diagnosed with an upper limb DVT. Due to their underlying lung disease, physiotherapy was mandatory for improvement. However, the DVT and anticoagulation treatment raised concerns for pulmonary emboli and hemoptysis. A framework for physiotherapy management in these patients, using a set of precautions and restrictions to maintain airway clearance while minimizing risk for pulmonary emboli and hemoptysis, was established. Using these set of instructions, the patients experienced no major adverse event while maintaining sufficient airway clearance to allow respiratory improvement. These precautions were continued until the upper limb DVTs resolved. To our knowledge there are currently no guidelines nor expert opinions available. Therefore, this framework can help guide physiotherapy management.

Role of a New Age-adjusted D-dimer Cutoff Value for Preoperative Deep Venous Thrombosis Exclusion in Elderly Patients With Hip Fractures

Objective: This study aimed to describe the characteristics of plasma D-dimer level with increasing age and establish a new age-adjusted D-dimer cutoff value for excluding preoperative lower limb deep vein thrombosis (DVT) in elderly patients with hip fractures.Methods: This was a retrospective study of elderly patients who presented with acute hip fracture in our institution between June 2014 and May 2020. All patients underwent D-dimer test and duplex ultrasound. Patients were divided into six 5-year-apart age groups. The optimal cutoff value for each group was calculated by using receiver operating characteristic (ROC) curves, whereby the new age-adjusted D-dimer cutoff value was determined. The sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) were calculated and compared when different D-dimer cutoff values were applied, i.e. conventional 0.5mg/L, previously well-established age-adjusted cutoff value (age*0.01 mg/L) and the new age-adjusted D-dimer cutoff value herein. Results: There were 2759 included, 887 males and 1872 females, with an average age of 77.8 years. 280 patients were diagnosed with preoperative DVT. The optimal cutoff values for the six age groups were 0.715 mg/L, 1.170 mg/L, 1.620 mg/L, 1.665 mg/L, 1.690 mg/L and 1.985 mg/L, respectively and the calculated age-adjusted coefficient was 0.02 mg/L. With this new coefficient applied, the specificity was 61.3%, clearly higher than those for conventional threshold (0.5mg/L, 36.9%) or previously established age-adjusted D-dimer threshold (age*0.01 mg/L, 22.2%). In contrast, the sensitivity was lower than that (58.9% vs 85.0% or 77.1%) when D-dimer threshold of 0.5 mg/L or age-adjusted cutoff value (age*0.01 mg/L) was used. The other indexes as PPV (14.7%, 11.0% and 12.1%) and NPV (93.0%, 92.9% and 93.5%) were comparable when three different D-dimer thresholds were applied. Conclusions: The use of the new age-adjusted D-dimer threshold increased the proportion of elderly hip fracture patients in whom preoperative lower limb deep vein thrombosis could be safely excluded.

Deep Vein Thrombosis in a Patient of Extrapulmonary Tuberculosis

Among the various complications reported to be caused by tuberculosis (TB), thrombogenic potential is a rare entity. Here, we report a case of colonic tuberculosis in a 30-year-old male who developed left upper limb deep vein thrombosis (DVT). Ruling out other possible causes of DVT and improvement of the affected limb with antitubercular drugs led to conclusion that DVT was most probably due to TB.

Multiple systemic paradoxical embolisation of a lower limb deep vein thrombosis due to interatrial septal puncture: a rare complication of left atrial appendage occlusion

A 75-year-old woman with a history of intracranial haemorrhage, atrial fibrillation and coronary artery bypass graft underwent elective left atrial appendage occlusion (LAAO) for stroke prevention. The procedure was successful, however on the third postoperative day, she presented with a lymph leak at the right femoral venous access site. She was admitted for conservative management of the lymph leak with immobility and intravenous fluids. Her inpatient stay was complicated by a right lower limb deep vein thrombosis (DVT), left middle cerebral artery territory ischaemic stroke, pulmonary emboli (PEs) and a splenic infarction. The mechanism of the systemic emboli was that of paradoxical emboli from the DVT passing through an interatrial septal defect created as part of the LAAO procedure, a previously unreported complication of LAAO. She was managed with 6 months of low-dose oral anticoagulation for treatment of DVT and PE and has made a full neurological recovery.

Vibrio fluvialis – Unusual Case of Cellulitis Leading to Sepsis

Vibrio fluvialis, an enteric, Gram negative bacterium commonly isolated from sewage/ sea water contaminated with human and animal’s faeces. Infections with this unusual organism can cause cholera like bloody diarrhoea and also wound infection. Vibrio fluvialis causing skin infection and sepsis is uncommon with very few cases reported worldwide. It is an emerging pathogen with distinct features as compares to the other species of Vibrio group of bacteria in terms of high virulence and adaptability in hostile environments. Here is a case report of skin and soft tissue infection by Vibrio fluvialis, in a patient suffering from severe pedal oedema due to nephrotic syndrome and right lower limb deep vein thrombosis . Case Report: A young male, farmer, presented with ascites, pedal oedema, puffy face due to nephrotic syndrome.He developed skin and soft tissue infection resulted from skin atrophy and ulcer due to pedal oedema as well as right limb deep vein thrombosis . He had high grade fever, leucocytosis, anaemia, hypoproteinaemia, right leg cellulites and features of sepsis requiring wound debridement. Immunodeficiency and corticosteroids associated immunosuppression were absent in this patient. He was diagnosed with nephrotic syndrome due to minimal change disease. Conclusion: Vibrio fluvialis infection can occur due to wound contaminated with sewage water leading to skin and soft tissue infection and life threatening sepsis.

A CASE OF UPPER LIMB DEEP VEIN THROMBOSIS IN A KNOWN HIV PATIENT WITH NON HODGKINS LYMPHOMA

This is a case of upper limb deep vein thrombosis in a HIV positive patient who had also been diagnosed of Non-Hodgkins Lymphoma. This case highlights the importance of thromboprophylaxis and thrombotic risk assessment in all HIV positive as well as cancer patients particularly in low resource setting which are at risk of increased morbidity and mortality.