Cardiovascular Disease |

A Fork in the Road: An Unusual Cause of Pulmonary Hypertension FREE TO VIEW

Sandeep Krishnan*, MD; Bashar Staitieh, MD; A. Maziar Zafari, MD; Gautam Kumar, MD
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Emory University, Atlanta, GA

Chest. 2012;142(4_MeetingAbstracts):104A. doi:10.1378/chest.1388553
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SESSION TYPE: Cardiovascular Student/Resident Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The World Health Organization divides pulmonary hypertension (PH) into five groups [1]. This case describes a unique presentation of Group V PH resulting from lymphomatous compression of the pulmonary arteries.

CASE PRESENTATION: A 38 year-old African American male with a history of HIV (CD4 count 516, undetectable viral load) and stage three Hodgkin's Lymphoma (HL) presented with complaints of dyspnea and palpitations. On exam he had jugulovenous distension and was hypotensive; TTE revealed cardiac tamponade. Emergent pericardiocentesis resulted in drainage of 1.5L of serosanguinous fluid from his pericardial sac. However, he continued to complain of dyspnea and post-procedural TTE still suggested elevated right-sided pressures and a possible mediastinal mass. A TEE revealed compression of both main branches of the pulmonary arteries after the bifurcation (Images 1A and 1B). CT chest confirmed extensive mediastinal lymphadenopathy resulting in mass effect on both pulmonary arteries (Image 2A). Emergent chemotherapy was initiated with ifosfamide, carboplatin and etoposide (ICE) and one month later, he was asymptomatic with complete resolution of the lymphadenopathy on follow-up CT (Image 2B).

DISCUSSION: There are several case reports in the literature of right ventricular outflow tract obstruction by mediastinal lymphadenopathy (usually non-HL) resulting in elevated right-sided pressures [2]. However, compression of the pulmonary arteries after their bifurcation with HL is a novel etiology. Although literature on this topic is limited, short term outcomes appear to be good with chemotherapy if the initial hemodynamic insult is tolerated.

CONCLUSIONS: Although the causes of dyspnea in a patient with lymphoma are myriad, pulmonary hypertension must be recognized and appropriately investigated so that outcomes may be optimized.

1) McLaughlin VV et al. American College of Cardiology Foundation Task Force on Expert Consensus Documents. American Heart Association. American College of Chest Physicians. American Thoracic Society, Inc. Pulmonary Hypertension Association ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol 2009. Apr;53(17):1575-78. doi: 10.1016/j.jacc.2009.01.004.

2) Russell, JC and Lowry, KG. Presentation of non-Hodgkin’s Lymphoma as acute hypoxia caused by right ventricular compression. Anesth Analg 2003;96:1768 -71.

DISCLOSURE: The following authors have nothing to disclose: Sandeep Krishnan, Bashar Staitieh, A. Maziar Zafari, Gautam Kumar

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Emory University, Atlanta, GA




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