[Deep venous thrombosis of the upper limb in a violin player: The "bow syndrome"].
BACKGROUND
Exercise-induced thrombosis is a rare cause of deep venous thrombosis (DVT) of the upper limb and usually affects young subjects without comorbid conditions. The diagnosis may be challenging.


METHODS
A 23-year-old female right-handed French teacher and amateur violin player presented with edema of the root of the right arm associated with erythrocyanosis of the extremity and collateral circulation of the shoulder. History taking revealed oral contraception and recent change in violin playing habits. D-dimers were negative. A second duplex-Doppler was required before visualization of a DVT in the right subclavian vein. The patient was given low-molecular-weight heparin alone, followed by rivaroxaban. The outcome was very favorable at 48h. The patient was seen at 4 months and had not had a recurrent episode.


CONCLUSIONS
The diagnosis of DVT of the upper limb is basically clinical. There is a clinical probability score for the introduction of anticoagulation even if the duplex-Doppler fails to visualize DVT, a situation that can occur due to the clavicular superposition in this region. Exercise-induced DVT should be suspected in patients with minimally intense but repeated exercise (hyper-abduction), e.g. as here playing the violin. Anticoagulation is the treatment of choice. The role for surgery and pharmacomechanical strategies remains to be defined.


CONCLUSIONS
Exercise-induced thrombosis (Paget-Schroetter syndrome) should be suspected in young patients free of any comorbidity who develop a thrombosis of the upper limb. Studies comparing different therapeutic options would be useful to achieve more homogeneous management practices despite the heterogeneous clinical presentations.
Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France. Electronic address: hsanson@hpsj.fr.
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Sanson
Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
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Gautier
Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
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Stansal
Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
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Sfeir
Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
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Franceschi
Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
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Priollet
D000925:Anticoagulants / Q000627:therapeutic use; D001132:Arm / Q000098:blood supply*; D001594:Benzyl Viologen; D015444:Exercise; D005260:Female; D006801:Humans; D009146:Music; D013350:Subclavian Vein / Q000000981:diagnostic imaging; D018616:Ultrasonography, Doppler, Duplex; D020246:Venous Thrombosis / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D055815:Young Adult
D000925:Anticoagulants; D001594:Benzyl Viologen
Deep venous thrombosis; Exercise-induced venous thrombosis; Paget-Schroetter; Syndrome de Paget-Schroetter; Thrombose veineuse du membre supérieur; Thrombose veineuse d’effort; Upper limb