Imaging diagnosis
Case 202
【Progress】
She was given anticoagulants and antiplatelets.
【Discussion】
Right ovarian vein directly flows out to inferior vena cava and left ovarian vein flows out to left renal vein. This is the same situation as testicular vein in male. Anatomically, the flow of left gonadal vein is susceptible to cause congestion due to speedy and voluminous left renal vein flow than that of right gonadal vein. Then, it leads to varicocele in male and pelvic congestion syndrome in female.
Meanwhile, ovarian vein thrombosis is susceptible to occur in right ovarian vein rather than left ovarian vein in terms of puerperium: right ovarian vein thrombosis 80%, left ovarian vein thrombosis 6%, both 14% (1 - 3). This is probably due to coagulopathic situation in puerperium and dextro-rotation of uterus compressing IVC and right ovarian vein (4, 5). The other factor is that right ovarian vein is usually antegrade and left ovarian vein can be retrograde easily (1, 2). Left ovarian vein is susceptible congestion which have already induced to form collateral pathways to pelvic veins. Then, although left ovarian vein tends to be congestive, left ovarian vein is hard to produce thrombosis.
However, in our case, left ovarian vein thrombosis occurred. We speculate that gynecologic infection from vagina to left fallopian tube or ovary first arises followed by coagulopathy in the left ovarian vein. Then, dehydration triggered to cause thrombosis in the left ovarian vein. Actually, she had mild fever for approximately 10 days and her laboratory test revealed persistent infection and dehydration.
Pulmonary embolism arises from primary thrombi in three venous branches (anterior tibial vein, posterior tibial vein and peroneal vein) and secondary thrombi in popliteal and femoral veins (6, 7). These thrombi become voluminously and migrate main pulmonary artery, inducing hypoxia and sudden death. In pregnancy or puerperium term, thrombi in right ovarian vein and inferior vena cava can be voluminous, inducing life-threatening. However, left ovarian vein thrombus cannot glow voluminously. Actually, contrast-enhanced CT showed occlusion of pulmonary artery branch, migrating from left ovarian vein, not inducing life-threatening but consistent cough in our case.
In our case, the value of Ig A was high, suspicious vasculitis. However, she did not have any skin erythema, nephritis and enteritis (8). It indicated that there was no proof of Ig A vasculitis. The value of D-dimer was high value, indicating fibrin formation in the vessel that reflect the thrombus formation of left ovarian vein and small pulmonary embolism (7).
【Summary】
We present a seventy one-year-old female for persistent fever and cough. Contrast-enhanced CT showed thrombus in the left ovarian vein and pulmonary embolism in left pulmonary branch artery. It is borne in mind that left gonadal vein irrespective of ovarian vein or testicular vein is susceptible to congestion due to that it drains to left renal vein while right gonadal vein drains directly to IVC. Left gonadal vein causes pelvic congestion syndrome or varicocele. However, it creates collateral pathway to pelvic veins, indicating hard to create thrombus. Meanwhile, left gonadal vein is susceptible to create thrombus especially in puerperium terms in female. In our case, it is considered that left ovarian vein thrombosis arised probably from gynecologic infection to left fallopian tube or ovary and dehydration.
【References】
1.Jenayah, AA et al. Ovarian vein thrombosis. Pan Afr Med J. 2015; 21: 251-260.
2.Salomon O, et al. New observations in postpartum ovarian vein thrombosis: experience of single center. Blood Coagul Fibrinolysis. 2010 Jan;21(1):16–19.
3.Martinelli I. Thromboembolism in women. Semin Thromb Hemost. 2006 Oct;32(7):709–715.
4.Kominiarek MA, et al. Postpartum ovarian vein thrombosis: an update. Obstet Gynecol Surv. 2006 May;61(5):337–342.
5.Deneux-Tharaux C, et al. Postpartum maternal mortality and cesariean delivery. Obstet Gynecol. 2006 Sep;108(3):541–548.
6.Kearon C. Diagnosis of pulmonary embolism. CMAJ. 2003 Jan;168(2):183–194.
7.Scarsbrook AF, et al. Diagnosis of suspected venous thromboembolic disease in pregnancy. Clin Radiol. 2006 Jan;61(1):1–12.
8.Perrier A, et al. Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: A multicenter management study. Am J Med. 2004 ;116:291–299.
9.Heineke MH, et al. New Insights in the Pathogenesis of Immunoglobulin A Vasculitis (Henoch-Schönlein Purpura). Autoimmun Rev 2017;16:1246-1253.
2020.8.26