SESSION TYPE: Miscellaneous Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary vein thrombosis has been sporadically reported in patients with malignancies, fungal infections, sclerosing mediastinitis, congenital pulmonary vein stenosis, and post lung transplant. We report the only case,to our knowledge, of pulmonary vein thrombosis associated with pneumonia.
CASE PRESENTATION: A 50 year-old woman with an acute exacerbation of sarcoidosis was treated with 40 mg prednisone daily for 8 weeks. Her clinical course was complicated by community acquired pneumonia of the right lower lobe that initially improved with moxifloxacin but worsened clinically and radiologically within a few weeks of cessation of antibiotics. On patient presentation, the previous pneumonia had progressed to a cavitatory lesion. She reported 3 weeks of fevers, right-sided chest pain, and malodorous brown sputum production. Contrast-enhanced chest CT revealed cavitatory pneumonia, a right pulmonary arterial thrombus, and a right inferior pulmonary vein thrombus extending into the left atrium.Bronchoscopic sampling did not demonstrate a pathogen. A CT-guided biopsy of the cavity was negative for any fungal elements or malignant cells, but detected necrotizing pneumonia. The culture grew Streptococcus anginosus and the anaerobic cultures grew Prevotella melaninogenica. Hypercoaguability workup was normal. An echocardiogram confirmed the left atrial and pulmonary vein thrombi. The infection was treated with 6 weeks of clindamycin. The thombus was managed with warfarin for 6 months.
DISCUSSION: The proposed pathogenesis of the above pulmonary vein thrombosis is local inflammation triggering vascular damage. Pulmonary vasculitis due to sarcoidosis is unlikely due to high-dose steroid treatment. The diagnosis depends on cost-effective and convenient imaging such as contrast-enhanced CT scans and other modalities such as MRI, trans-esophageal echocardiogram, and pulmonary angiogram. Treatment data are limited. Although surgical options such as thrombectomy, lobectomy(in cases with pulmonary gangrene) and resection(for tumor thrombi) are reported, our case was managed medically. Anticoagulation therapy has been anecdotally reported.Additionally, a survival benefit has been demonstrated in dogs treated conservatively with antibiotics, owing to development of pulmonary venous collateral circulation. The benefit of warfarin in prevention of thrombus propagation and systemic embolization potentially outweighs the risk of bleeding.
CONCLUSIONS: Pulmonary vein thrombosis is a rare disease which may complicate anaerobic lung infections and can be visualized on CT imaging.Amongst the different treatment modalities that have been anecdotally published,our case supports conservative management.
1) Williamson WA, Tronic BS, Levitan N, Webbjohnson DC, Shahian DM, Ellis FH. Pulmonary venous infarction. Chest 1992;102:937-40.
2) Selvidge SDD, Gavant ML. Idiopathic pulmonary vein thrombosis: Detection by CT and MR imaging. American Journal of Roentgenology 1999;172:1639-41
DISCLOSURE: The following authors have nothing to disclose: Tushar Chopra, William Gibbons, Karin Provost
No Product/Research Disclosure InformationState University of New York at Buffalo, UB, Buffalo, NY