Deep Vein Thrombosis /Pulmonary Embolism in a Patient with Retroperitoneal Fibrosis: A Case Report

Introduction: Retroperitoneal Fibrosis (RPF) is a clinicopathological condition characterized by inflammatory fibrotic reaction around infrarenal aorta, iliac vessels and surrounding retroperitoneum with myriad presentations. This case report shows how a Deep Vein Thrombosis (DVT) and subsequent Pulmonary Embolism (PE) can be a potential complication of this disease. A potential temporal association was seen with chronic beta blocker use and retroperitoneal fibrosis. Case presentation: A 62-year-old Caucasian male with history of hypertension on chronic beta-blocker therapy for 2 years (Metoprolol 50 mg twice daily) presented with sub-acute left sided non-radiating lower back pain of 5-day duration. Computerized Tomography (CT) scan with contrast of the abdomen and pelvis revealed large segment of inflammatory stranding involving the periaortic retroperitoneum extending from the level of the kidneys upto the pelvis and incasing the left Iliac veins. CT guided retroperitoneal core biopsy was done which was consistent with retroperitoneal fibrosis. Two months later, patient presented with complain of acute onset shortness of breath and increasing lower extremity edema, on the left side. Electrocardiogram was consistent with a finding of new onset Atrial fibrillation (A fib). Ultra Sono Gram (USG) Doppler study of lower extremities unveiled occlusive left sided DVT of the popliteal vein. A CT Angiography demonstrated segmental and sub-segmental pulmonary emboli of the right lower lobe with no evident pulmonary edema. He was treated with steroids, digoxin and warfarin. On follow up a repeat CT scan three months later of the abdomen and pelvis showed stable retroperitoneal mass with no further progression. Conclusion: Our patient presented with lower extremity edema and imaging revealed extension of RPF to involve common iliac vessels. With beta-blockers as a possible inciting event, RPF causing venous stasis, iliac vein compression and thus DVT/PE is the most plausible explanation This case reports add to the medical literature how DVT/PE can be cause by an underlying disease entity not related to the usual causes and if not worked up patients may be labeled as having unprovoked events. Any relationship between beta blockers and RFP is questionable and has not been proven in any randomized trials, but should be thought of by the physician if such clinical situation is encountered. *Corresponding author: Harsh Agrawal, Department of Internal Medicine, University of California, Los Angeles-Olive View Program, David Geffen School of Medicine, Los Angeles, 14445 Olive View Drive, 2B-182, Sylmar CA, 91342, CA, USA, E-mail: [email protected] Received May 31, 2012; Accepted June 13, 2012; Published June 23, 2012 Citation: Agrawal H, Bishop CI, Wali S, Sealey ML (2012) Deep Vein Thrombosis /Pulmonary Embolism in a Patient with Retroperitoneal Fibrosis: A Case Report. J Clin Case Rep 2:154. doi:10.4172/2165-7920.1000154 Copyright: © 2012 Agrawal H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Retroperitoneal Fibrosis (RPF) is a clinico pathological condition characterized by inflammatory fibrotic reaction around infra renal aorta, iliac vessels and surrounding retroperitoneum with myriad presentations [1]. Major advancements have been made since then towards understanding the disease process, though lack of definite diagnostic criteria and treatment protocol still remains a challenge. RPF has estimated incidence of 1-2 per 100,000 [2]. Given the rarity of the condition the diagnosis may often be missed if not included in differential diagnosis in appropriate clinical background. It is imperative to identify and treat RPF early on in its course in order to avoid potentially devastating complications including Deep Vein Thrombosis, Pulmonary Embolism, reno-vascular hypertension, ureteric obstruction, Chronic Kidney Disease (CKD) [3]. Here we describe a case of RPF in a patient on chronic beta blocker therapy who later presented with unilateral DVT and PE. Our objectives are to consider RPF as one of the potential complication of chronic beta– blocker therapy and to recognize DVT/PE as a potential complication of RPF.