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Un edem de cauza improbabila

Un edem de cauza improbabila. Dr. Vlad Teodor Berbecar Medic Rezident an I Medicina Interna Institutul Clinic Fundeni. Barbat , 30 ani Tumefactie si durere la nivelul membrului inferior drept (gamba + coapsa ) Simptome care au aparut relativ brusc (in 48h). Istoric.

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Un edem de cauza improbabila

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  1. Un edem de cauzaimprobabila Dr. Vlad TeodorBerbecar Medic Rezident an I MedicinaInterna Institutul Clinic Fundeni

  2. Barbat, 30 ani • Tumefactie si durere la nivelul membrului inferior drept (gamba + coapsa) • Simptome care au aparutrelativbrusc (in 48h)

  3. Istoric • Fara APP sau AHC semnificative • Multipli FRCV (fumator, supraponderal) • Sofer de tir • De mentionat: in urma cu 2 sapt => junghitoracic bilateral cu tusesiexpectoratieruginie, farafebra; radiologic s-a decelat imagine de lichid pleural bilateral in cantitate mica interpretata ca infectie respiratorie => tratament antibiotic cu evolutie initial favorabila.

  4. Clinic • stare generala buna • TA=125/70 mmHg, AV=100 b/min • stetoacustic pulmonar si cardiac normal • edem la nivelul gambei si coapsei drepte cu cianoza si durere locala • semnul Homans pozitiv pe dreapta

  5. Diagnostic prezumtiv:TrombozavenoasaprofundaDiagnostic diferential:-insuficientavenoasa / obstructievenoasa-limfedem-chist Baker rupt-rupturamusculara/hematom-sindrom de compartiment-celulita-erizipel

  6. Paraclinic • leucocitoza (12.000/mmc), • sindrom inflamator (fibrinogen=742 mg/dl, PCR=104 ng/dl, VSH=105), • sindrom anemic – anemie microcitara, hipocroma (Hb=9.7 mg/dl), • sindrom de retentie azotata (creatinina=3.13 mg/dl) • hiperpotasemie (K=6.99 mmol/l) • hipoalbuminemie (albumina=2g/dl) • sindrom nefrotic (proteinurie=5.4 g/24h) • D-Dimeri pozitivi (860 U/l) • ANA, cANCA, pANCA normale, markeri virali (hepatici, HIV) negativi

  7. EcoDoppler vascular: tromboza de ax venos iliac drept; v. poplitee si v. femurala superficiala in 1/3 distal a coapsei sunt partial compresibile, ceea ce sugereaza ca tromboza ar fi putut avea o evolutie descendenta pornind de la venele abdominale

  8. CT cu s.c. i.vtromboza extensiva de VCI si axe venoase iliacemai extins pe partea dreapta, precum si la nivelul venelor renale mai ales pe partea dreapta, cu arii hipoperfuzate renale bilateral

  9. glomerulonefrita primitiva vs • sindrom nefrotic secundar trombozei venelor renale.

  10. Tratament • anticoagulant (initial heparina, apoi AVK) si s-a realizat tromboliza(cu 750.000 UI streptokinaza) cu repermeabilizarea partiala a VCI • evolutie favorabila • scaderea semnificativa a edemului, • scaderea sindromului de retentie azotata • remiterea hiperpotasemiei • persistenta proteinuriei si a D-dimerilor

  11. punctie biopsie renala => Glomerulonefrita membranoasa • .

  12. s-a initiat tratamentul cu Ciclosporina si Prednison

  13. Discutii • Pacienttanar, fara APP • Tromboza de vase mari • Glomerulonefritamembranoasa (8-10cazuri/mil loc; 55 ani) • Status procoagulant

  14. Vamultumesc Bibliografie: • KDIGO Clinical Practice Guideline for Glomerulonephritis, Kidney International Supplements (2012) 2, 259–274 • Approach to Leg Edema of Unclear Etiology, John W. Ely, MD, MSPH, Jerome A. Osheroff, MD, M. Lee Chambliss, MD, MSPH, and Mark H. Ebell, MD, MS; (J Am Board Fam Med 2006;19:148–60.) • http://emedicine.medscape.com/article/1933035-overview# • The diagnosis and treatment of venous thromboembolism, Philip Wells and David Anderson, ASH Education Book December 6, 2013vol. 2013 no. 1 457-463 • Prothrombotic disorders in abdominal vein thrombosis, Leebeek FW1, Smalberg JH, Janssen HL, NethJ Med. 2012 Nov;70(9):400-5. • Swaminathan S, Leung N, Lager DJ, Bergstralh EJ, Rohlinger A, Fervenza FC: Changing Incidence of Glomerular Disease in Olmsted County, Minnesota: A 30-Year Renal Biopsy Study.Clin J Am SocNephrol(2006) 1: 483–487.

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