SESSION TYPE: Miscellaneous Student/Resident Cases I
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Pulmonary vein thrombosis (PVT) is classically seen after thoracic surgical procedures but a rarely reported event. We present a case of spontaneous PVT in a patient with known malignancy.
CASE PRESENTATION: A 54 year old male with advanced parotid gland adenocarcinoma presented with a two month history of cough, dyspnea, scant hemoptysis, and without constitutional symptoms. He had no history of thromboembolism and was currently on no chemotherapy. Physical exam was notable for tachycardia, normal respiration, and an oxy-hemoglobin saturation of 96% breathing ambient air. Laboratory data revealed mild anemia and normal coagulation. His chest x-ray is shown in Figure 1. A CT pulmonary angiogram slice is shown in Figure 2. There was no evidence of pulmonary artery embolus but multiple left sided pulmonary venous thrombi were present.
DISCUSSION: PVT has been documented after thoracic surgical procedures, reported with blunt chest trauma and radiofrequency ablation of atrial fibrillation but there are few reported cases of spontaneous PVT. The clinical presentation of PVT is nonspecific with dyspnea, cough, hemoptysis, and/or pleuritic chest pain being reported. Signs of PVT are common to other disorders and include tachypnea and tachycardia. Chest x-ray findings of PVT include air space consolidation due to pulmonary congestion or hemorrhage. CT angiography to assess for pulmonary arterial embolism can detect PVT when delayed images are acquired. The role of hypercoaguable conditions in spontaneous PVT is uncertain. Our patient, with active malignancy, was at an increased risk of thrombotic events. There is scant literature to guide therapy of spontaneous PVT. Case reports indicate that systemic anticoagulation may prevent clot propagation and embolization. In cases of large PVT, thrombectomy has been implemented.
CONCLUSIONS: Our patient was admitted for systemic anticoagulation. A month after his presentation his dyspnea was improved and he had no recurrent hemoptysis. Given the nonspecific presentation, spontaneous PVT may be more common than realized. PVT should be considered in patients who present with new pulmonary infiltrates who lack infectious symptoms, particularly in those at increased risk for thrombotic events or in those with features of systemic thromboembolism. Acute pulmonary arterial embolism shares many of the features of PVT. CT angiography can be used to identify both of these entities if PVT is considered in the diagnostic evaluation.
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DISCLOSURE: The following authors have nothing to disclose: Kevin Maguire, Paul Simonelli, Rajiv Panikkar, Cynthia Tsai, Jason Stamm
No Product/Research Disclosure InformationGeisinger Medical Center, Danville, PA