Pediatric Thromboembolism Clinical Presentation

Updated: May 23, 2019
  • Author: Scott C Howard, MD; Chief Editor: Hassan M Yaish, MD  more...
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Presentation

History

Elicit a history of previous thrombosis. Document the age at which thrombosis occurred and the type of thrombosis (DVT, PE, myocardial infarction, stroke) that developed. Also obtain a thorough family history.

The contribution of the following factors to thrombosis is most thoroughly documented in adults, but these factors can contribute to thrombosis in children as well:

  • Recent surgery

  • Trauma

  • Immobilization

  • Prolonged bedrest

The use of estrogen-containing medications, such as oral contraceptives, increases the risk of thrombosis in women and female adolescents. The risk is further increased in those who are heterozygous for factor V Leiden or have other prothrombotic risk factors.

Heart disease

Congenital heart disease and/or recent cardiac catheterization are the most common causes of arterial thrombosis in children. Noteworthy factors include the following:

  • Dizziness

  • Bilateral extremity swelling

  • Poor weight gain

Malignancy

A history or symptoms suggestive of malignancy should prompt inquiry about use of central venous catheters and recent chemotherapy with L-asparaginase. Some advocate a search for occult malignancy in adults who develop thrombosis with few risk factors (“unprovoked thrombosis”), but this is not necessary in children since thrombosis is very rarely the first sign of cancer.

Deep venous thrombosis

Symptoms of DVT can include an acute onset of pain and swelling of the affected limb(s). These symptoms are nonspecific and can have multiple etiologies, including trauma, sports injuries, congestive heart failure, or nephrotic syndrome.

Pain and swelling

The amount of pain can range from none to severe. The degree of pain is typically associated with the speed of onset of thrombosis; a clot that develops quickly and causes a lot of blood flow blockage and inflammation typically hurts more than one that develops slowly with minimal blood vessel obstruction or a clot that causes obstruction gradually, leaving time for collateral circulation to develop.

A classic example of asymptomatic venous thrombosis is thrombosis around central venous catheters (in one study, 37% of children developed such thrombosis, but only a fifth of those had any symptoms). [19] However, swelling and pain in an upper extremity may suggest thrombosis if a central venous catheter or other localized risk factors are present.

Pulmonary embolism

Symptoms of PE can include an acute onset of chest pain and shortness of breath. Chest pain due to PE is usually not constant; most chest pain in children does not signify a significant medical condition. In adults, the first sign of PE may be cardiovascular collapse, cardiac arrest, or sudden death.

CNS thrombosis

Symptoms of CNS thrombosis include vomiting, lethargy, seizures, and weakness in an extremity. Most strokes that occur in utero cause early, pathologic hand preference late in the first year of life.

Neonates often present with seizures and lethargy. Older children usually present with headaches and an acute onset of weakness in an extremity.

Infection and dehydration are common precipitating causes of CNS thrombosis among infants and young children.

Renal vein thrombosis

Patients with renal vein thrombosis may present with flank pain and hematuria.

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Physical Examination

In children, as well as in adults, findings from the physical examination are often misleading. A diagnosis of thrombosis may be missed or delayed because of the nonspecific nature of the patient's presenting signs.

Although DVT is frequently asymptomatic, signs of the condition can include the following:

  • Leg or arm edema

  • Erythema

  • Increased warmth

  • Palpable cord

  • Tenderness

  • Positive Homans sign (ie, pain on dorsiflexing the foot)

Other important features in patients with thromboembolism are predisposing conditions, such as those listed below:

  • Congestive heart failure or heart disease

  • Malignancy

  • Presence of a central venous catheter

Thrombosis of the inferior vena cava and/or renal vein can cause nephromegaly and flank tenderness.

Signs of PE are nonspecific and include the following:

  • Apprehension

  • Diaphoresis

  • Tachycardia

  • Tachypnea

  • Chest pain

  • Hypotension

Hemoptysis is seldom present in children but can be a sign in adolescents or adults.

Signs of arterial thrombosis include absent or diminished peripheral pulses and a cool extremity with or without mottling of the skin.

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