Abstract

To the Editor:

A typical or unusual symptoms may signal the presence of a life-threatening condition,¹ as the following case illustrates.

A 72-year-old female with hypertensive nephropathy required placement of a temporary hemodialysis catheter into her right subclavian vein for symptomatic chronic renal failure. The catheter was placed via fluoroscopic guidance without complication and hemodialysis was commenced without incident. After two weeks of dialysis, the patient presented to the emergency department complaining of severe right ear pain, involving the posteromedial aspect of the auricle and external canal. She denied fever, vertigo, tinnitus, or hearing loss. Examination revealed a normal external ear without erythema, warmth, or tenderness; the auditory canal was normal, but there was tenderness over the sternocleidomastoid. Ultrasound of the neck veins revealed acute thrombus involving the right internal jugular and subclavian veins, with near total occlusion. Laboratory testing disclosed normal erythrocyte and leukocyte counts, but the platelet count was 88,000 cells/mm³. The platelet count predialysis was normal. The patient was admitted and started on intravenous heparin, but the following morning the platelet count decreased to 24,000 cells/mm³. Heparin was discontinued. There was no evidence of microangiopathic anemia, and argatroban was administered. A heparin-induced platelet antibody test was strongly positive. After 5 days of argatroban, the platelet count returned to normal, warfarin was commenced, and the otalgia resolved.