a 68-year - old woman visited the clinic with the chief complaints of pain , swelling , and a warm sensation in her left thigh for over 2 days prior to her visit .
the patient also complained about a warm sensation during the nighttime but body temperature was normal when measured in the clinic .
she had undergone a left bipolar hemiarthroplasty following a hip fracture 24 days prior to the current visit and was wearing compression stockings to prevent the occurrence of a deep vein thrombosis .
she had been taking aspirin 100 mg daily , fexonadine 180 mg daily , and hydrea 500 mg twice a day for a diagnosis of polycythemia vera for 1 year and was phlebotomized in a hemato - oncology setting on an irregular basis . in advance of the operation , her erythrocyte sedimentation rate ( esr ) , and c - reactive protein ( crp ) levels were 30 mm / hr and 4.99 mg / dl , respectively .
three days after her hip surgery , her esr and crp levels were 23 mm / hr and 6.35 mg / dl , respectively .
medical care was administered in close cooperation with the hemato - oncology department and the level of hemoglobin was maintained at < 12 g / dl to prevent a thrombosis prior to her operation .
the patient did not have a fever and her skin color seemed normal despite swelling and a slight warm sensation in the left hip and proximal femur .
results of a blood test showed that her complete blood count , electrolyte levels , and liver function were all within normal ranges ( white blood cell count [ wbc ] : 4,700/l , hemoglobin : 10.6 g / dl , hematocrit : 32.3% , platelet : 213,000/l , neutrophil count 67.2% , lymphocyte 24.1% , monocyte 6.8% ) whereas the esr and crp level were 38 mm / hr and 8.25 mg / dl , respectively . when compared to tests performed previously , no further observations of additional fractures , signs of infection , or loosening of inserts after the surgery
acute or sub - acute inflammation was diagnosed given the perfusion image of soft tissue in the left hip area as well as the blood pool image ( fig .
the patient was injected intravenously with antibiotics for 1 week while staying in the hospital , however , symptoms were not alleviated . in order to prevent a deep vein thrombosis , the patient started to move with the aid of a wheelchair and exercised her knee joints 3 days after the operation .
g / dl , a color doppler ultrasonography was performed due to her history of polycythemia vera .
results revealed a deep vein thrombosis in the common femoral vein as well as in the superficial femoral vein ( fig .
symptoms were alleviated following the administration of low - molecular - weight heparin ( enoxaparin , 40 mg ) and warfarin ( 5 mg ) for 5 days .
additional warfarin was prescribed ( 2.5 mg daily ) for maintenance at discharge . during her first follow - up visit 2 weeks later , no symptoms were noted and all blood test parameters were within normal ranges .
it has been reported that patients with polycythemia vera present with various complications related to thrombosis due to excessive blood viscosity1 ) .
several putative reasons have been postulated to explain such complications including hypervolemia , an increase in the volume of red blood cells , telangiectasia due to decreased blood flow velocity as well as vascular elasticity , thrombocytosis , and complex hemostatic disorders attributable to inefficient blood clotting processes2 ) .
thrombosis is the leading cause of death in those with polycythemia vera and has been associated with high morbidity as well .
approximately 12 - 49% of patients with polycythemia vera experience thrombosis and 20 - 40% will die as a result2 ) .
thromboembolism is one of the major complications of hip surgery and contributes to its poor prognosis .
warwick et al.3 ) reported that the incidence rate for a deep vein thrombosis was about 1.89% if proper medication was not provided after total hip arthroplasty .
therefore , in the case of the patient described in the current case report , it was reasonable to expect that she would be susceptible to the high incidence rate of thrombosis as she underwent the hip surgery based on her history of polycythemia vera . for prophylactic purposes ,
aspirin was administrated ( 100 mg daily ) and early exercise and active movements were recommended for the patient in order to lower the risk of venous thromboembolism . in the current case report , a patient with polycythemia vera exhibited clinical symptoms and signs of a postoperative infection following bipolar hemiarthroplasty due to femoral neck fractures .
there was , however , a deep vein thrombosis which rendered the intravenous administration of antibiotics ineffective in the alleviation of symptoms .
early symptoms of a deep vein thrombosis , including swelling , pain , oppressive pain , and a warm sensation , can mimic those of a postoperative infection .
furthermore , features of systematic inflammatory responses such as increased levels of interleukin-6 , interleukin-8 , and crp may be observed in patients with a deep vein thrombosis .
collectively , these findings suggest that appropriate clinical examinations are warranted at an early stage in order to avoid making an inaccurate diagnosis4,5 ) . on the first visit after the operation ,
the patient was suspected to have had a postoperative infection due to the simultaneous increase in esr and crp levels
. however , the specificity of esr and cpr levels pertaining to the diagnosis of infections is questionable , as most patients display elevated levels of esr and crp following a hip surgery6 ) .
these inflammatory responses stimulate the production of cytokines due to the fractures and operation per se , thus biochemical parameters for inflammation are known to be elevated in a non - specific manner . in cases without postoperative infections , elevated crp levels recover to the normal range within 3 weeks of the operation6,7 ) . in the current case report , the elevated crp level that was maintained for up to 24 days after the operation led us to suspect a postoperative infection .
however , the abnormally increased level of acute phase reactants ( e.g. , crp ) may be observed in patients with chronic myeloproliferative diseases ( e.g. , polycythemia vera ) and therefore further specific clinical examinations are required for an infectious diagnosis8 ) . regarding the diagnosis of a postoperative infection ,
elevated level of serum procalcitonin may be more valuable than wbcs and crp levels7 ) .
regrettably , the level of serum procalcitonin was not measured in the current case but could have been informative in distinguishing between postoperative infection and a deep vein thrombosis . despite the presentation of similar clinical symptoms between a postoperative infection and a deep vein thrombosis , their etiological mechanisms are completely distinct . therefore ,
different treatments are warranted , as patients receiving inappropriate medical treatments may experience exacerbated symptoms and conditions .
the potential for a deep vein thrombosis requires continuous thought and attention regarding relevant examinations for patients at high risk for thrombosis as well as for embolism ( e.g. , polycythemia vera ) .
 a 68-year - old woman who suffered from polycythemia vera presented at our clinic with the chief complaints of pain , swelling , and a warm sensation in her left thigh . 
 she had undergone a left bipolar hemiarthroplasty following a hip fracture 24 days prior to this presentation . 
 her erythrocyte sedimentation rate and c - reactive protein ( crp ) levels were elevated . 
 in addition , a postoperative infection was suspected in the 3-phase bone scan ; therefore , she received intravenous antibiotic therapy . 
 this approach proved to be ineffective and she was subsequently diagnosed with a deep vein thrombosis via color doppler ultrasonography . 
 it is interesting to note that a deep vein thrombosis can present with symptoms similar to those of a postoperative infection . 
 furthermore , an elevated crp level is frequently observed in patients suffering from polycythemia vera . 
 therefore , the two conditions , which require completely different treatments , can be confused . 
 we report on this case with a review of the relevant literature . 
CASE REPORT
DISCUSSION