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Jeon S, Hong JM, Lee HJ, Kim E, Lee H, Kim Y, Ri HS, Lee JJ. Acute lower extremity arterial thrombosis after intraocular foreign body removal under general anesthesia: A case report and review of literature. World J Clin Cases 2021; 9:8232-8241. [PMID: 34621886 PMCID: PMC8462198 DOI: 10.12998/wjcc.v9.i27.8232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/08/2021] [Accepted: 08/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Surgery, which is a major risk factor for venous thrombosis, has rarely been considered a risk factor for arterial thrombosis. Recent studies have suggested that venous and arterial thromboses share common risk factors and have a bidirectional relationship. Accordingly, there is a growing interest in the risk of arterial thrombosis after surgery. We report a case of acute bilateral lower extremity arterial thromboses that developed after a prolonged surgery.
CASE SUMMARY A 59-year-old man was hospitalized for intraocular foreign body removal surgery. He was a heavy-drinking smoker and had untreated hypertension and varicose veins in both legs. The operation was unexpectedly prolonged, lasting 4 h and 45 min. Immediately after emergence from general anesthesia, the patient complained of extreme pain in both legs. After the surgical drape was removed, cyanosis was evident in both feet of the patient. The pulse was not palpable, and continuous-wave Doppler signals were inaudible in the bilateral dorsalis pedis and posterior tibial arteries. Computed tomography angiography confirmed acute bilateral thrombotic occlusion of the popliteal arteries, proximal anterior tibial arteries, and tibioperoneal trunks. Arterial pulse returned in both lower limbs after 6 h of heparin initiation. The patient was discharged on postoperative day 26 without any sequelae.
CONCLUSION Acute lower extremity arterial thrombosis can occur after surgery. Anesthesiologists should pay particular attention to patients with risk factors for thrombosis.
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Affiliation(s)
- Soeun Jeon
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan 49241, South Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Jeong-Min Hong
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan 49241, South Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Hyeon Jeong Lee
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan 49241, South Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Eunsoo Kim
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan 49241, South Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Hyunju Lee
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan 49241, South Korea
| | - Yesul Kim
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Busan 49241, South Korea
| | - Hyun-Su Ri
- Department of Anesthesia and Pain Medicine, Kyungpook National University, School of Medicine, Daegu 41944, South Korea
| | - Jae Jung Lee
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
- Department of Ophthalmology, College of Medicine, Pusan National University, School of Medicine, Yangsan 50612, South Korea
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Sun L, Li X, Li Q, Wang L, Li J, Shu C. Multiple arterial and venous thromboembolism in a male patient with hereditary protein C deficiency: A case report. Medicine (Baltimore) 2021; 100:e25575. [PMID: 33847687 PMCID: PMC8052080 DOI: 10.1097/md.0000000000025575] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/31/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Hereditary protein C deficiency has a high prevalence in Asian populations, being the important risk factor associated with thrombophilia. Traditionally, conservative medication is the first choice for patients with hereditary protein C deficiency. However, there are few reports on whether aggressive surgical treatment can be performed when patients continue to develop life-threatening ischemic symptoms after adequate anticoagulant and thrombolytic therapy. PATIENT CONCERNS A 40-year-old male presented with right lower extremity pain for 1 week. DIAGNOSIS Computed tomography angiography (CTA) of lower extremity indicated arterial embolization of the right superficial femoral artery. Vascular ultrasonography showed old extensive thrombus in the deep vein of the left lower extremity. Electrocardiogram reported old anterior myocardial infarction. Sequencing of the gene encoding protein C (PROC) gene revealed that a heterozygous in-frame deletion mutation (c.577-579delAAG, p.192delK). Based on these findings, the diagnosis of hereditary protein C deficiency was made. INTERVENTIONS The patient was given low-molecular-weight heparin (LMWH) anticoagulation and urokinase treatment immediately. Then we performed the Fogarty catheter embolectomy with about 18.5 cm thrombus being removed and utilized the balloon catheter to dilate the anterior tibial artery. Despite given adequate anticoagulant and thrombolytic therapy postoperatively, the patient still had new thrombosis, and eventually underwent arterial embolectomy and amputation. OUTCOMES The patient was discharged with good wound healing and continued rivaroxaban treatment at a dose of 20 mg daily. The patient was followed-up monthly until 1 year: there was no adverse ischemic events occurred. LESSONS Aggressive surgical treatment may be the effective attempt for life-saving when conservative treatment as the first choice had unsatisfactory results in hereditary protein C deficiency patients. The novel oral anticoagulants (NOACs) could be more suitable than warfarin for the treatment and prevention of recurrence in patients with hereditary protein C deficiency.
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Affiliation(s)
- Likun Sun
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University
- Vascular Disease Institute of Central South University, Changsha
| | - Xin Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University
- Vascular Disease Institute of Central South University, Changsha
| | - Quanming Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University
- Vascular Disease Institute of Central South University, Changsha
| | - Lunchang Wang
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University
- Vascular Disease Institute of Central South University, Changsha
| | - Jiehua Li
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University
- Vascular Disease Institute of Central South University, Changsha
| | - Chang Shu
- Department of Vascular Surgery, The Second Xiangya Hospital of Central South University
- Vascular Disease Institute of Central South University, Changsha
- Department of Vascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Ohashi I, Wada S, Yoshino F, Kuwashiro T, Matsumoto S, Hotta T, Kang D, Okada Y, Shimohama S, Yasaka M. Ischemic Stroke with Protein S Deficiency Treated by Apixaban. J Stroke Cerebrovasc Dis 2020; 29:104608. [PMID: 31941580 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/03/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023] Open
Abstract
A 57-year-old man with atherosclerosis obliterans was admitted with sudden-onset sensory aphasia and right hemiparesis. Brain MRI revealed acute cerebral infarctions in the left temporal lobe and magnetic resonance angiography showed occlusion of the posterior branch of the left middle cerebral artery. Transesophageal echocardiography and ultrasonography respectively confirmed a patent foramen ovale and deep vein thrombosis in the bilateral femoral veins. Blood findings showed low protein S antigen, low protein S activity, and a missense mutation of the PROS 1 gene. The administration of apixaban 10 mg BID prevented ischemic stroke recurrence and decreased the deep vein thrombosis. These outcomes indicated that apixaban may be alternative to warfarin for the secondary prevention of ischemic stroke in a patient with a protein S deficiency.
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Affiliation(s)
- Ikkei Ohashi
- Division of Cerebrovascular Medicine and Neurology, National Hospitalization Organization, Kyushu Medical Centre, Japan; Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Shinichi Wada
- Division of Cerebrovascular Medicine and Neurology, National Hospitalization Organization, Kyushu Medical Centre, Japan.
| | - Fumitaka Yoshino
- Division of Cerebrovascular Medicine and Neurology, National Hospitalization Organization, Kyushu Medical Centre, Japan
| | - Takahiro Kuwashiro
- Division of Cerebrovascular Medicine and Neurology, National Hospitalization Organization, Kyushu Medical Centre, Japan
| | - Shinya Matsumoto
- Department of Clinical Chemistry and Laboratory Medicine, Graduates School of Medical Sciences, Kyushu University, Japan
| | - Taeko Hotta
- Department of Clinical Chemistry and Laboratory Medicine, Graduates School of Medical Sciences, Kyushu University, Japan
| | - Dongchong Kang
- Department of Clinical Chemistry and Laboratory Medicine, Graduates School of Medical Sciences, Kyushu University, Japan
| | - Yasushi Okada
- Division of Cerebrovascular Medicine and Neurology, National Hospitalization Organization, Kyushu Medical Centre, Japan
| | - Shun Shimohama
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
| | - Masahiro Yasaka
- Division of Cerebrovascular Medicine and Neurology, National Hospitalization Organization, Kyushu Medical Centre, Japan
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Omental gangrene and porto-mesenteric thrombosis in a patient of protein C and protein s deficiency. Indian J Surg 2014; 75:409-11. [PMID: 24426632 DOI: 10.1007/s12262-012-0751-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 09/11/2012] [Indexed: 10/27/2022] Open
Abstract
Omental gangrene is an infrequent cause of acute abdomen with unclear etiology. Hypercoagualable states like protein C or protein S deficiency have never been implicated in the etiology of omental gangrene. We present this case report of a patient having protein C and protein S deficiency presenting with omental gangrene and extensive porto mesenteric thrombosis.
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Crawford JD, Wong VW, Deloughery TG, Mitchell EL, Liem TK, Landry GJ, Azarbal AF, Moneta GL. Paroxysmal nocturnal hemoglobinuria: a red clot syndrome. Ann Vasc Surg 2013; 28:122.e5-10. [PMID: 24200143 DOI: 10.1016/j.avsg.2013.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 07/09/2013] [Accepted: 07/23/2013] [Indexed: 11/30/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired, nonmalignant disorder of hematopoietic stem cells characterized by hemolysis, diminished hematopoiesis, and thrombophilia. We describe a 65-year-old woman with known PNH and peripheral arterial disease who presented with critical limb ischemia and a nonhealing left foot ulcer. She underwent surgical bypass of a diffusely diseased left superficial femoral artery with autologous reversed saphenous vein graft. Her postoperative course was complicated by wound sepsis and PNH exacerbation with resultant graft thrombosis requiring an above-knee amputation. This case highlights several key concepts relevant to the management of vascular surgery patients with PNH: (1) their predisposition for arterial and venous thrombosis; (2) hypercoagulability despite standard anticoagulation regimens; (3) the role of eculizumab (a monoclonal antibody that inhibits complement activation used to treat PNH) in reducing thrombotic complications and hemolysis; and (4) complications associated with the immunosuppressive effects of eculizumab. We recommend careful monitoring of hemolysis and immunosuppression, aggressive anticoagulation, frequent graft surveillance, and early consultation with hematology.
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Affiliation(s)
- Jeffrey D Crawford
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Victor W Wong
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Thomas G Deloughery
- Division of Hematology and Oncology, the Department of Internal Medicine, Oregon Health and Science University, Portland, OR
| | - Erica L Mitchell
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Timothy K Liem
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Gregory J Landry
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Amir F Azarbal
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Gregory L Moneta
- Division of Vascular Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR.
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Acute aortoiliac thrombotic occlusion in an infant with protein C deficiency and small atrial sepal defect--a rare case. J Pediatr Surg 2013; 48:658-60. [PMID: 23480928 DOI: 10.1016/j.jpedsurg.2012.12.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 12/18/2012] [Accepted: 12/28/2012] [Indexed: 10/27/2022]
Abstract
Aortoiliac thrombosis is rare in infants and neonates. Protein C deficiency is frequently observed with venous thromboembolism, but off-late report of arterial thrombosis is increasingly common. We report a case of large infrarenal aortoiliac saddle and right popliteal artery thrombosis in a 7-month-old infant, with 3-mm atrial septal defect without clinical and Doppler evidence of deep vein thrombosis, presented with acute bilateral lower limb ischemic attack. Diagnosis was made by computed tomographic (C T) angiography of aorta and bilateral lower limbs. Patient operated on in emergency by transperitoneal route. Aortoiliac and right popliteal artery thromboembolectomy with closure of aortotomy with polytetraflouroethylene patch was performed.
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A case of a patient with protein C deficiency presenting with concurrent thromboses in the pulmonary arteries and innominate artery: a suggestive computed tomographic finding of thrombophilia. J Thorac Imaging 2012; 27:W180-1. [PMID: 22487990 DOI: 10.1097/rti.0b013e3182475424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of arterial thrombosis in patients with protein C deficiency is relatively low compared with that of venous thrombosis. To our knowledge, there is no previously published report of a protein C deficiency patient with simultaneous thromboses in the pulmonary artery and innominate artery in the English literature. We present a case of a protein C deficiency in which the presence of concurrent clots in the pulmonary arteries and innominate artery demonstrated on a pulmonary computed tomographic angiography provided an important clue permitting diagnosis of the deficiency.
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Affiliation(s)
- Julian Ilcheff Borissoff
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute of Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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Palareti G, Valdré L, Favaretto E, Bovina V, Cini M, Legnani C. No early signs of atherosclerotic alterations in carriers of inherited thrombophilia. Eur J Intern Med 2010; 21:273-7. [PMID: 20603034 DOI: 10.1016/j.ejim.2010.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Revised: 04/05/2010] [Accepted: 04/25/2010] [Indexed: 01/10/2023]
Abstract
BACKGROUND Congenital thrombophilia is a risk factor for venous thromboembolism (VTE). Whether it is associated with increased risk of arterial disease is today a matter of debate. We aimed to look for early signs of atherosclerotic alterations in carriers of inherited thrombophilic alterations (ITA). METHODS Between January 2006 and September 2008 ultrasonography assessment of the carotid arteries with measurement of intima-media thickness (IMT), and determination of the ankle/brachial pressure index (ABI), was performed in: a) 161 carriers of ITA (deficiency of antithrombin, protein C or S, factor V Leiden or prothrombin G20210A mutations), 84 of whom with previous VTE, and b) 180 subjects without ITA, matched for age, sex and previous VTE. All subjects were <66 year old. RESULTS Carotid plaques were found in 8 subjects [3 (1.9%) with ITA]. Increased IMT values (>1mm) were detected in 6 subjects with and 1 without thrombophilia (p=0.055). The prevalence of IMT values>90(th) percentile was not different in subjects with/without thrombophilia (15.2% vs 11.6%, p=0.416). At multivariate analysis only age was significantly associated with increased odds ratios for IMT values>90(th) percentile. No subjects had abnormal (<0.9) ABI values. CONCLUSIONS The present study, the first to investigate the presence of atherosclerotic markers in relatively young subjects with inherited thrombophilia, did not find a particular prevalence of signs of early atherosclerotic markers in these subjects.
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Affiliation(s)
- Gualtiero Palareti
- Dept. Angiology & Blood Coagulation Marino Golinelli, University Hospital S. Orsola-Malpighi, Bologna, Italy.
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Chasing Clot: Thrombophilic States and the Interventionalist. J Vasc Interv Radiol 2009; 20:1403-16; quiz 1417. [DOI: 10.1016/j.jvir.2009.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 07/07/2009] [Accepted: 08/24/2009] [Indexed: 01/08/2023] Open
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Abstract
Popliteal artery occlusion is a rare vascular complication in athletes and has not been previously documented in baseball players. A 21-year-old male baseball player presented with a 10-month history of progressive claudication because of repeated trauma-induced popliteal artery occlusion from frequently practicing stealing bases by sliding down onto his right leg. He was found to have a transient deficiency in both protein C and protein S. The patient underwent percutaneous transluminal recanalization angioplasty followed by anticoagulation therapy, with good results. This case illustrates the importance of awareness of this potential complication in baseball athletes, work-up for a hypercoagulable state and the feasibility of angioplasty therapy in the management of ischemic limbs after trauma.
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Affiliation(s)
- Mindy Ming-Huey Guo
- Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan
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Gmeiner M, Pfeifer J. Management of complications in surgery of the colon. Eur Surg 2007; 39:15-32. [PMID: 32288768 PMCID: PMC7102154 DOI: 10.1007/s10353-007-0311-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Accepted: 01/23/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly. METHODS We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads). RESULTS Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery. CONCLUSIONS To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.
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Affiliation(s)
- M. Gmeiner
- />Department of Pulmology, General Hospital Graz-West, Graz, Austria
| | - J. Pfeifer
- />Department of General Surgery, Medical University of Graz, Graz, Austria
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McKay D, Marron C, Brown R. Testicular infarction secondary to protein S deficiency: a case report. BMC Urol 2006; 6:17. [PMID: 16827935 PMCID: PMC1543644 DOI: 10.1186/1471-2490-6-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Accepted: 07/07/2006] [Indexed: 11/22/2022] Open
Abstract
Background Protein S deficiency is an inherited cause of thrombophilia. We present the second reported case in the literature of a man developing testicular infarction secondary to protein S deficiency. Case presentation A 63 year old man presented with sudden onset of pain in his left hemi-scrotum. Despite oral warfarin therapy the plasma INR was only 1.4 at presentation. Doppler ultrasound scan of the scrotum confirmed absent blood flow to the left testis with increased echogenicity. Orchidectomy was performed to remove the necrotic testis. Post-operatively the patient did well and was referred to the Regional Haemophilia and Thrombosis Centre for further management. Conclusion The case highlights a rare but potential complication of protein S deficiency and demonstrates the importance of adequate anticoagulation in these patients.
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Affiliation(s)
- Damian McKay
- The Department of Surgery, Daisy Hill Hospital, Newry, Co Down, BT35 8DR, N. Ireland, UK
- C/O The Department of Surgery, The Institute of Clinical Science, The Royal Victoria Hospital, Belfast, BT12 6BA, N. Ireland, UK
| | - Conor Marron
- The Department of Surgery, Daisy Hill Hospital, Newry, Co Down, BT35 8DR, N. Ireland, UK
| | - Robin Brown
- The Department of Surgery, Daisy Hill Hospital, Newry, Co Down, BT35 8DR, N. Ireland, UK
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