Unprovoked pulmonary thromboembolism predisposed by hyperhomocysteinemia

The role of hyperhomocysteinemia as a predisposing factor for coronary artery disease has been discussed in several text and reports but its role in venous thrombosis has seldom been discussed. A 42-year-old woman was admitted to our hospital with a history of swelling of lower limbs of 7 days duration, breathlessness of 5 days duration. She had no significant history of prior illness. On physical examination, the temperature was 99.6 °F, pulse rate 86 beats per minute, and blood pressure 100/60 mm Hg. Clinical examination of the cardiovascular system was normal. The routine laboratory analysis was normal. D-dimer level was 1.718 μg/mL. Biochemical studies and urinalysis were in normal range. Based on the clinical, laboratory, and radiological findings, computed tomographic pulmonary angiography (CTPA) was performed. Echocardiogram revealed dilated pulmonary arteries dilated and dysfunctional right ventricle, pulmonary hypertension with severe tricuspid regurgitation. Computed tomographic pulmonary angiography demonstrated the presence of pulmonary embolism involving both the pulmonary artery. Screening for thrombophilic states demonstrated normal protein C, protein S, and anti-thrombin III was negative. Anti-phospholipid antibody was negative. Homocysteine level was 149.6 μmol/which formed the sole predisposing factor for the event in this case. The patient was planned for lifelong prophylactic anticoagulation with acitrom overlapped by heparin initially; along with folic acid, pyridoxine and vitamin B12. The follow up has been uneventful. Initiating supportive medications for hyperhomocysteinemia in patients with thrombotic events may have remarkable effect on prognosis and incidence of recurrence.