Age: 46.0
Sex: M
Vaccine: COVID19
Symptoms: Pulmonary artery dilatation, Pulmonary embolism, Russell's viper venom time normal, Sarcoidosis, Skin ulcer
Clinical narrative: Recurrent venous thrombosis, mult episodes of left lower extremity DVT with May Thurner syndrome, one episode of left upper extremity DVT, and one episode of pulmonary embolism and 3 stasis ulcers, all of which except the first deep venous thrombosis occurred on anticoagulation, traditional dose Coumadin has failed him and higher dose INR wildly fluctuated, and one mg/kg bid Lovenox, and Xarelto, now on bid lovenox for an antiXa levels, goal 1-1.2  Prior hypercoag workup has shown homozygosity for C677T mutation in the MTHFR gene with elevated homocystine, negative for prothrombin gene mutation, negative for factor V Leiden mutation, anti-3 thrombin activity normal at 102%, negative anticardiolipin antibodies, history of low protein C and S but while on Coumadin.  Approximately 1995 he developed his first left lower extremity DVT of the calf and thigh, he was placed on Coumadin, goal INR 2-3  Approximately 1999 he developed worsening left lower extremity symptoms, was noted to have a second episode of DVT left lower extremity with new symptoms, he continued on Coumadin  Approximately 2002 he developed pelvic phlebitis and continued on Coumadin  March 2014, post trauma, developed left upper extremity DVT, left upper extremity ultrasound showed subacute to chronic appearing occlusive thrombus, left basilic and lower cephalic vein, stayed on Coumadin, INR was 2.8 at the time  November 2015 left lower extremity new symptoms with third DVT, INR 3.5 at the time, left lower extremity ultrasound showed extensive acute appearing left lower extremity DVT, switched to Xarelto, interventional radiology did angioplasty and stenting of the left common and left external iliac vein  January 2017, definite new symptoms with fourth left lower extremity DVT, CT abdomen pelvis showed occluded left common femoral vein and external iliac vein stent with multiple collateral vessels which had been seen in June 2016, stayed on Xarelto  February 2017 worsening progressive left lower extremity fifth DVT, interventional radiology performed catheter directed thrombolysis, the clot was "like cement", lateral lower extremity ultrasound showed extensive acute appearing incomplete occlusive thrombus of the common femoral vein to the popliteal vein, right lower extremity was negative, he was switched to Lovenox 1 mg/kg twice daily  March 2017 new pulmonary symptoms, CT angio showed acute segmental and subsegmental left lower lobe pulmonary emboli, prominent distal right paraesophageal lymph node 9 mm without change from January 2017, with possible other reactive lymphadenopathy locally, small hiatal hernia, and diffuse hepatic steatosis, diagnosed with pulmonary embolism, placed on Lovenox bid with anti-10 a dosing goal of 1, at 140 mg twice daily, recent EGD was normal, left lower extremity ultrasound at the time showed persistent or redevelopment of extensive occlusive left femoral-popliteal DVT  16 May 2017, admit to KU w/ recurrent LLE DVT, ext occ thrombus LLE and no e/o PE, transitioned to lovenox bid goal antiXa 1-1.2, on 150 mg bid  Oct 2017, 10 hr drive, new superficial thrombophlebitis near the left medial malleolus, recommended adding aspirin 81 mg daily until superficial thrombophlebitis resolved (not done til Mar 2018)  7 September 2018 thrombectomy, successful in lower extremity but unsuccessful at iliac, IVC filter placed (with plans for subsequent removal), followed by 31 October 2018 right saphenous vein graft to the left saphenous vein, with great success, Plavix added to Lovenox, Lovenox prescribed at 100 mg twice daily, increased back to 150 mg twice daily with recent anti-X A of 1.28, November 2018  19 February 2019 new occlusive superficial thrombus left foot and ankle, no change in chronic thrombosis left femoral and popliteal  5 March 2019 no change from February 2019  17 June 2019 left lower extremity ultrasound partial thrombosis of the left common femoral and superficial femoral veins and possible chronic thrombus in the left popliteal vein CT angiogram 17 June 2019 shows no pulmonary embolism, new prominent mediastinal, hilar and paraesophageal and portacaval lymph nodes which are nonspecific and may be reactive, metastatic disease or lymphoma cannot be excluded, lymph nodes up to 15 mm on short axis  September 2019 he had EBUS through pulmonary with suspected granulomas, I cannot find pathology but see this reported in notes as suspicious sarcoid  24 October 2019 persistent chronic occlusion left lower extremity ultrasound at left common femoral vein, deep femoral vein, popliteal veins, with chronic left iliac vein occlusion  February 2020 arterial and venous lower extremity ultrasound show no arterial blockages however chronic left lower extremity venous findings persist  IVC filter removal June 2020  Follow-up August 2020 some left lower extremity phlebitis to the mid ankle symptoms, stasis wound has healed  Feb 2021 umbilical hernia repair with some slight hypercoagulability afterwards, added very low-dose aspirin only until symptoms improve, aware bleeding risks increased 2/16/21 us LLE for inc phlebitis sx of L foot, Overall no significant change in post thrombotic scarring involving the common femoral, deep femoral, femoral, and popliteal veins since 5/27/2020. No evidence of acute deep venous thrombosis in the left lower extremity. Patent venous bypass graft in the left groin.   covid vaccine 3/17 pfizer lot EN6204, and 4/13/2021 pfizer lot #EW0151 (LLE sx worsened after pfizer vaccines)  Bone mineral density 2 June 2021 showed a Z score of -2.0  12 June 2021 left lower extremity ultrasound showed acute nonocclusive thrombus at left common femoral vein at greater saphenous vein junction with probable acute nonocclusive mild thrombus low femoral vein and no change in diffuse chronic thrombus with patent venous bypass graft 12 June 2021 CT angio no PE, lymphadenopathy secondary to sarcoid without change, mild enlargement in pulmonary arterial trunk  15 June 2021 TTE normal but PA pressure could not be calculated Anticoagulation switched from Lovenox, 150 mg twice daily, w/ wt 96 kg, w/ anti-Xa on 12 June 2021 of 1.14, to Coumadin with a goal INR of 4.0, of note he has clotted with an INR of 3.5 in the past, and continues on aspirin 81 mg daily with Plavix and fish oil and will add vitamin E over-the-counter, a home INR machine is pending, labs in June showed protein C of 102%, protein S of 97.9%, anticardiolipin antibodies negative, beta-2 glycoprotein antibodies negative, hexagonal lupus anticoagulant negative, DRVVT negative.   27 Oct 2021, change back to lovenox 150 mg SQ bid due to difficulty getting Coumadin therapeutic, as well Covid vaccination was likely a reversible risk factor and he will avoid further Covid vaccinations