DOI: https://doi.org/10.36347/sjmcr.2025.v13i12.004

Pages: 2921-2925

Background: Isolated distal deep vein thrombosis (DVT) in particular gastrocnemius or soleal muscular veins forms a special diagnostic problem because of the subtle symptoms and lack of sensitivity of the usually used tools such as D-dimer and Wells scores. Concomitant SVT increases the risk for progression of thrombus and adds clinical importance to early recognition. However, the general practice or primary care physicians commonly resort to clinical prediction rules or laboratory tests which may not reliably rule out distal DVT. Case Presentation: A 53-year-old woman with a past history of varicose veins, BMI 35 kg/m², previous SVT and current use of hormone replacement therapy (HRT) was seen at the clinic for local tenderness and lump in the left calf over six weeks. On examination, there was a well localised tender nodule with no swelling or erythema. Laboratory assessment showed a negative D-dimer (<190 µg/L FEU) and the Wells score was –1, indicative of low risk of DVT. However, duplex ultrasonography revealed a non-compressible thrombus in the left gastrocnemius vein, measuring approximately 2 cm from the popliteal junction and a segment of 4 cm SVT within varicose veins. She was managed with apixaban and her symptoms improved. Conclusion: This case illustrates that isolated gastrocnemius vein thrombosis with associated SVT can develop in the setting of reassuring lab values and low clinical probability scores. Localized calf symptoms that are persistent need to be imaged regardless of what the D-dimer and Wells score say. Direct oral anticoagulants (DOACs) offer safe and convenient treatment for these presentations.