The Hidden Clot: A Case of Recurrent Atypical Venous Thrombosis Highlighting the Need for Vigilant Diagnostic Evaluation
DOI:
https://doi.org/10.19166/med.v15i2.10592Keywords:
Venous thromboembolism, unusual site thrombosis, inferior vena cava thrombosis, renal vein thrombosis, ovarian vein thrombosisAbstract
Background:
Venous thromboembolism (VTE) is the third most common cardiovascular disorder worldwide. While lower-extremity deep vein thrombosis and pulmonary embolism are typical presentations, thrombosis in atypical sites remains challenging to recognize and diagnose.
Case Description:
A 27-year-old female flight attendant with history inflammatory bowel disease (IBD), tuberculosis and combined oral contraceptive (COC) use presented with an acute abdominal pain. Initial contrast-enhanced CT revealed thrombosis of the left renal and ovarian veins. Laboratory tests showed elevated hs-CRP and D-dimer, with positive ANA but negative antiphospholipid antibodies. She was treated with intravenous heparin followed by oral rivaroxaban, though adherence was inconsistent due to episodes of heavy vaginal bleeding. Repeat CT imaging eight months later demonstrated resolution of the initial thrombi but revealed a new thrombus in the inferior vena cava extending into the right common iliac vein, accompanied by recurrent elevation of D-dimer.
This case illustrates the interplay of multiple risk factors for VTE, including IBD, prolonged immobility during long-haul travel, COC use, tuberculosis, and rifampicin therapy. These overlapping chronic and transient triggers likely contributed to recurrent thrombosis despite ongoing treatment.
Conclusions:
Recurrent VTE in unusual venous sites can occur particularly in patients with multiple risk factors. Early recognition, appropriate imaging, and anticoagulant therapy adherence are essential to preventing progression and recurrence
References
1. Khan F, Tritschler T, Kahn SR, Rodger MA. Venous thromboembolism. Lancet Lond Engl. 2021 July 3;398(10294):64–77. https://doi.org/10.1016/s0140-6736(20)32658-1
2. Olson MC, Lubner MG, Menias CO, Mellnick VM, Mankowski Gettle L, Kim DH, et al. Venous Thrombosis and Hypercoagulability in the Abdomen and Pelvis: Causes and Imaging Findings. RadioGraphics. 2020 May;40(3):190097. https://doi.org/10.1148/rg.2020190097
3. Yamashita Y, Morimoto T, Kimura T. Venous thromboembolism: Recent advancement and future perspective. J Cardiol. 2022 Jan;79(1):79–89. https://doi.org/10.1016/j.jjcc.2021.08.026
4. Heit JA. Epidemiology of venous thromboembolism. Nat Rev Cardiol. 2015 Aug;12(8):464–74. https://doi.org/10.1038/nrcardio.2015.83
5. Tambunan KL, Kurnianda J, Suharti C, Wardhani SO, Sukrisman L, Soetandyo N, et al. IDENTIA Registry: Incidence of Deep Vein Thrombosis in Medically Ill Subjects at High Risk in Indonesia: A Prospective Study. Acta Medica Indones. 2020 Jan;52(1):14–24.
6. Afzal A, Conyers FG, Sauk S, Schaefer JK. Venous Thromboembolism in Unusual Locations. Med Clin North Am. 2025 July;109(4):887–905. https://doi.org/10.1016/j.mcna.2025.01.007
7. Mount HR, Rich M, Putnam MS. Recurrent Venous Thromboembolism. Am Fam Physician. 2022 Apr;105(4):377–85.
8. Rao K, Aswani Y, Bindner H, Patel A, Averill S, Davis T, et al. Intra-abdominal Venous Thromboses and Their Management. Acad Radiol. 2024 Aug;31(8):3212–22. https://doi.org/10.1016/j.acra.2023.12.018
9. Black S, Choudhury E. Venous thrombosis. Surg Oxf. 2022 July 1;40(7):401–10. https://doi.org/10.1016/j.mpsur.2022.05.009
10. Khan F, Rahman A, Carrier M, Kearon C, Weitz JI, Schulman S, et al. Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis. BMJ. 2019 July 24;366:l4363. https://doi.org/10.1136/bmj.l4363
11. Alshahrani S, Alfawzan A, Alswaidan A, Alkharaan A, Alabduljabar M, Khan A, et al. Anatomical Sites and Clinical Characteristics of Venous Thromboembolism in a Tertiary Hospital. J Appl Hematol. 2020 Sept;11(3):126. https://doi.org/10.4103/joah.joah_32_20
12. Abbattista M, Capecchi M, Martinelli I. Treatment of unusual thrombotic manifestations. Blood. 2020 Jan 30;135(5):326–34. https://doi.org/10.1182/blood.2019000918
13. Alkhouli M, Morad M, Narins CR, Raza F, Bashir R. Inferior Vena Cava Thrombosis. JACC Cardiovasc Interv. 2016 Apr 11;9(7):629–43. https://doi.org/10.1016/j.jcin.2015.12.268
14. Tahir N, Sherchan R, Farooqi A, Shrestha J, Jeelani HM. Idiopathic Ovarian Vein Thrombosis: A Rare Cause of Abdominal Pain. Cureus. 13(7):e16756. https://doi.org/10.7759/cureus.16756
15. Stadnicki A, Stadnicka I. Venous and arterial thromboembolism in patients with inflammatory bowel diseases. World J Gastroenterol. 2021 Oct 28;27(40):6757. https://doi.org/10.3748/wjg.v27.i40.6757
16. Johnson IM, Shatzel J, Olson S, Kohl T, Hamilton A, DeLoughery TG. Travel-Associated Venous Thromboembolism. Wilderness Environ Med. 2022 June;33(2):169–78. https://doi.org/10.1016/j.wem.2022.02.004
17. LaVasseur C, Neukam S, Kartika T, Samuelson Bannow B, Shatzel J, DeLoughery TG. Hormonal therapies and venous thrombosis: Considerations for prevention and management. Res Pract Thromb Haemost. 2022 Aug 1;6(6):e12763. https://doi.org/10.1002/rth2.12763
18. Miyahara T, Nishino Y, Ozaki M, Ogiwara M. Renal Vein Thrombosis Occurring in Association with Oral Contraceptives: A Case Report. Ann Vasc Dis. 2023 June 25;16(2):131–4. https://doi.org/10.3400/avd.cr.22-00129
19. Danwang C, Bigna JJ, Awana AP, Nzalie RNT, Robert A. Global epidemiology of venous thromboembolism in people with active tuberculosis: a systematic review and meta-analysis. J Thromb Thrombolysis. 2021 Feb 1;51(2):502–12. https://doi.org/10.1007/s11239-020-02211-7
20. Choy KR, Emmett S, Wong A. Venous thromboembolism prophylaxis in pregnancy: Are we adequately identifying and managing risks? Aust N Z J Obstet Gynaecol. 2022;62(6):915–20. https://doi.org/10.1111/ajo.13579
21. Karande GY, Hedgire SS, Sanchez Y, Baliyan V, Mishra V, Ganguli S, et al. Advanced imaging in acute and chronic deep vein thrombosis. Cardiovasc Diagn Ther. 2016 Dec;6(6):493–507. https://doi.org/10.21037/cdt.2016.12.06
22. Afzal A, Conyers FG, Sauk S, Schaefer JK. Venous Thromboembolism in Unusual Locations. Med Clin North Am. 2025 July;109(4):887–905. https://doi.org/10.1016/j.mcna.2025.01.007
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Gladys Mangkuliguna, Ratna Sutanto, Olivia Violetta, Andree Kurniawan
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Authors who publish with this journal agree to the following terms:
1) Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-SA 4.0) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
2) Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
3) Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website). The final published PDF should be used and bibliographic details that credit the publication in this journal should be included.
