title: Portal, superior mesenteric and splenic vein thrombosis secondary to hyperhomocysteinemia with pernicious anemia: a case report.
abstract: BACKGROUND
  Acute portomesenteric vein thrombosis is an uncommon but serious condition with potential sequelae, such as small-bowel gangrene and end-stage hepatic failure. It is known to be caused by various pro-thrombotic states, including hyperhomocysteinemia. We describe what is, to the best of our knowledge, the first reported case of concomitant thrombosis of portal, superior mesenteric and splenic veins due to hyperhomocysteinemia secondary to pernicious anemia and no other risk factors.
  
  
  METHODS
  A 60-year-old Indian man presented with epigastric pain, diarrhea and vomiting. An abdominal imaging scan showed that he had concomitant pernicious anemia and concomitant portal, superior mesenteric and splenic vein thrombosis. A work-up for the patient's hypercoagulable state revealed hyperhomocysteinemia, an undetectable vitamin B12 level and pernicious anemia with no other thrombophilic state. He developed infarction with perforation of the small bowel and subsequent septic shock with multi-organ dysfunction syndrome, and he ultimately died due to progressive hepatic failure.
  
  
  CONCLUSIONS
  This report demonstrates that pernicious anemia, on its own, can lead to hyperhomocysteinemia significant enough to lead to lethal multiple splanchnic vein thrombosis. Our case also underscores the need to (1) consider portomesenteric thrombosis in the differential diagnosis of epigastric abdominal pain, (2) perform a complete thrombotic work-up to elucidate metabolic abnormalities that could be contributing to a pro-thrombotic state and (3) initiate aggressive measures, including early consideration of multi-visceral transplantation, in order to avoid decompensation and a significant adverse outcome.
authors.forename: Prashanth
authors.initials: P
authors.lastname: Venkatesh
authors.affiliation: Weill Cornell Medical College in Qatar, Ar-Rayyan, Qatar. nissatfirdous99@gmail.com.
authors.forename: Nissar
authors.initials: N
authors.lastname: Shaikh
authors.forename: Mohammad F
authors.initials: MF
authors.lastname: Malmstrom
authors.forename: Vajjala R
authors.initials: VR
authors.lastname: Kumar
authors.forename: Bakr
authors.initials: B
authors.lastname: Nour
mesh_terms: D000752:Anemia, Pernicious / Q000150:complications* / Q000175:diagnosis; D003937:Diagnosis, Differential; D017809:Fatal Outcome; D006801:Humans; D020138:Hyperhomocysteinemia / Q000150:complications* / Q000175:diagnosis; D017093:Liver Failure / Q000209:etiology; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008642:Mesenteric Veins / Q000000981:diagnostic imaging / Q000473:pathology; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology; D011169:Portal Vein / Q000000981:diagnostic imaging / Q000473:pathology; D013162:Splenic Vein / Q000000981:diagnostic imaging / Q000473:pathology; D014057:Tomography, X-Ray Computed / Q000379:methods; D014463:Ultrasonography; D020246:Venous Thrombosis / Q000175:diagnosis / Q000209:etiology*; D014806:Vitamin B 12 Deficiency / Q000175:diagnosis / Q000209:etiology