A 25 year old left hand-dominant man presented with swelling and mild numbness of the left arm of three days duration. Just a day before the onset of the swelling, he carried a heavy television set to his house. He had a history of pleural tuberculosis which was successfully cured after anti-tuberculosis treatment. He denied any past history of surgery and intravenous drug use. No family history of a similar illness was detected. Clinical examination revealed few dilated veins in the arm and the upper left half of the chest, which became more prominent during Valsalva's manoeuvre. The left upper limb showed normal arterial pulses and there was no neurological deficit or bony injury. A Doppler ultrasonography confirmed thrombosis of the left subclavian/axillary vein. Other investigation results including x-rays of the left shoulder and chest, computerized tomography of the upper chest and complete blood count (CBC) were all normal. The coagulation profile revealed activated partial thromboplastin time (aPTT) and prothrombin time (PT) within normal range while the international normalized ratio (INR) was 1.0.
The patient was treated as an outpatient with low molecular weight heparin (LMWH) for 6 days and then maintained on oral warfarin for 6 months. A Doppler imaging done after the third month of initiation of warfarin treatment revealed complete recanalization of the subclavian/axillary vein and development of collateral circulation. The patient was followed for three years without any apparent complications or relapse except a mild occasional pain on the affected limb.