1647 - Proximal Median and Axillary Neuropathies from Upper Extremity DVT: A Case Report

Right proximal median and axillary neuropathies secondary to right upper extremity DVT, with superimposed rotator cuff tear.

Case Description: A 68-year-old male diagnosed with viral URI experienced two-weeks later atraumatic right shoulder pain and proximal arm swelling. He later developed right upper extremity numbness, tingling, and weakness. Physical examination of the right upper extremity was notable for sensory loss in the median nerve distribution, and thumb abduction and shoulder weakness. Ultrasound of the right upper extremity revealed deep venous thrombosis and was treated with apixaban but neurologic deficits persisted. While right shoulder MRI demonstrated a full-thickness supraspinatus tear, electrodiagnostic testing ordered demonstrated absent right median sensory responses and denervation in axillary and distal and proximal median-innervated muscles, favoring right proximal median and axillary neuropathies secondary to venous congestion and nerve compression. The patient was prescribed analgesics following anticoagulation cessation and proceeded with physical therapy. Brachial plexus MRI remains under consideration.

Discussions: This case highlights the diagnostic complexity across musculoskeletal, vascular, and neurologic processes. Rotator cuff tears can mask or coexist with nerve injuries; electrodiagnostic studies show associated brachial plexus involvement in up to 28% of cases. Venous congestion from thrombosis can cause compressive proximal upper extremity neuropathies, producing weakness and sensory loss in these respective nerve distributions. The combination of arm swelling, persistent neuropathic symptoms, and electrodiagnostic abnormalities suggest most likely primary vascular pathology complicated by neuropathies. Electrodiagnostic testing was essential to localize dysfunction to specifically the proximal median and axillary distributions, findings the shoulder MRI would not necessarily account for.

Conclusions: Venous congestion can precipitate proximal upper extremity neuropathies, and it is crucial to evaluate for these given persistent neurological deficits despite treatment of associated DVT. Electrodiagnostic testing was vital for refining the diagnosis and enabling targeted rehabilitation, particularly as shoulder MRI findings could not solely account for the patient’s presentation.