U.S, 14 October 2021, Hussain et al, Case Reports in Critical Care
A 21-year-old male without significant past medical history presented to the emergency department 8 days after receiving the Ad26.COV2.S vaccine, with complaints of left groin pain and inability to bear weight on the left leg. On initial evaluation, he was noted to have mild erythema and edema of the left leg with circumferential diameter 40 cm comparative to 38 cm of the right leg. He was recommended to follow supportive care with conservative approach and discharged home. A day later, he presented to the emergency department with worsening swelling of the left leg. On examination, left lower extremity edema was consistent with prior exam with new skin changes concerning for phlegmasia cerulea dolens. Lower extremity duplex showed absent blood flow in the left common femoral, profundal femoral, femoral, and calf veins due to occluding thrombus visualized from the iliac, femoral, popliteal to the left posterior tibial, and peroneal vein. Complete blood count including platelet count was normal. Coagulation panel included an elevated INR at 14.3, PTT at 120 sec, and decreased fibrinogen at 172 mg/dl. He was noted to be negative for heparin-dependent platelet antibody (PF4) enzyme-linked immune sorbent assay (ELISA) IgA/M/G and serotonin release assay.
He also received hypercoagulable workup for Factor V Leiden mutation, Prothrombin gene, serum homocysteine, anti-phospholipid antibody panel, antithrombin III activity, and protein C&S activity which were all unremarkable for underlying hypercoagulable etiology. He required left lower extremity venography with pharmacomechanical thrombolysis/thrombectomy with venous thrombolysis and placement of 16mm x 100mm left common iliac venous stent. He was maintained on direct thrombin inhibitor with argatroban, which was transitioned to oral apixaban upon discharge from the hospital. Venous duplex in one week is to be repeated. He will continue to follow with Hematology Outpatient.