A 4-Year-Old Girl in Significant Distress

Alba Morales Pozzo, MD


March 05, 2019


This patient has either a deep femoral venous thrombosis or a thrombus within another of the deep veins of the right lower extremity, most likely as a complication of CVC placement in a very young patient with severe diabetic ketoacidosis.

The typical signs and symptoms associated with deep venous thrombosis (DVT) of an extremity are persistent extremity edema with or without pain or changes in skin color, prominent superficial veins, tenderness, pain with passive dorsiflexion of the foot (Homans sign), and peripheral cyanosis. Signs and symptoms tend to be nonspecific and can vary in severity depending on the size of the thrombus and extent of venous occlusion. An example in an adult is shown in Figure 1.

Figure 1.

CVC use in the pediatric population is increasing, which has caused an increase in the incidence of pediatric DVT. CVCs can increase the risk for DVT by causing vascular damage and causing turbulent blood flow in the vessel (Figure 2).

Figure 2.

When compared with the adult population, thromboembolism in pediatric patients is rare, with most of cases occurring in hospitalized children. In 1845, Virchow described the three important factors in the development of a thrombus as follows:

  • Impairment of blood flow

  • Vascular injury

  • Alterations in the blood (hypercoagulability)

Common risk factors for thrombus formation include the following:

Persons with poorly controlled diabetes seem to have abnormalities of hemostasis, but the mechanism that causes the problem is not well understood. Clinical studies in patients with diabetic ketoacidosis have demonstrated transient changes in coagulation factors (increased platelet activation, fibrinolytic activity, and endothelial activation).[1,2,3] Diabetic ketoacidosis is also accompanied by an enhanced inflammatory state, with increased levels of cytokines, C-reactive protein, and complement activation. The combination of diabetic ketoacidosis and CVC placement may be a significant risk factor for the development of DVT.


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