SESSION TITLE: Pulmonary Vascular Disease Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary vein thrombosis (PVT) is a rare disease entity usually associated with lung malignancy, radiofrequency ablation of atrial fibrillation, lung surgery or transplantation. We discuss an extremely rare case of idiopathic PVT.
CASE PRESENTATION: A 70-year-old African American male, with history of tobacco abuse, COPD, and hypertension, presented with worsening dyspnea, atypical chest pain, and productive cough for 2 days. He had no fever, hemoptysis or recent immobilization. Physical examination was unremarkable except for mild bilateral wheezing. Chest X-ray showed lung hyperinflation with no evidence of pneumonia. CT of the chest revealed emphysematous changes and left lower PVT without pulmonary infarction, masses, or pulmonary embolism. Transesophageal echo (TEE) revealed decreased blood flow in left lower pulmonary vein with no evidence of anatomic stenosis, but due to the limited study thrombus was not identified. Patient had age-appropriate cancer screening with negative colonoscopy 3 months prior to admission. Hypercoagulability work up was negative. Patient was started on anticoagulation with warfarin and enoxaparin, in addition to bronchodilators and a short course of steroids.
DISCUSSION: Only 5 cases of idiopathic PVT have been previously reported. PVT can present with cough, hemoptysis, dyspnea, and pleuritic chest pain or as progressive or recurrent pulmonary edema and pulmonary fibrosis. Rare complications of PVT, such as pulmonary gangrene and peripheral embolization, have been reported. A combination of diagnostic modalities can aid in diagnosis, including transthoracic echocardiography, TEE, pulmonary angiography, MRI, and CT. The appropriate management of PVT remains unclear, and frequently is dependent on the underlying etiology. Long-term anticoagulation can help prevent thrombus progression and peripheral embolization.
CONCLUSIONS: Though initial management was targeted towards COPD exacerbation in our patient, further investigation was warranted as symptoms persisted. We believe our patient presented as a case of PVT mimicking a COPD exacerbation. One may argue that the TEE finding of decreased flow is suggestive of but not conclusive of PVT. As we were convinced with the CT finding of PVT, anticoagulation was started and patient was scheduled for follow up MRI. In our opinion, it is necessary to perform age appropriate cancer screening and a hypercoagulability profile to rule out secondary causes of PVT, as 2 cases of idiopathic PVT had associated abnormal thrombophilia profiles.
Reference #1: Wu, J. P., et al. "Idiopathic pulmonary vein thrombosis extending to left atrium: a case report with a literature review." Chinese medical journal 125.6 (2012): 1197
Reference #2: Selvidge SD, Gavant ML. Idiopathic pulmonary vein thrombosis: detection by CT and MR imaging. AJR Am J Roentgenol 1999; 172: 1639-1641
Reference #3: Alexander GR, Reddi A, Reddy D. Idiopathic pulmonary vein thrombosis: a rare cause of massive hemoptysis. Ann Thorac Surg 2009; 88: 281-283
DISCLOSURE: The following authors have nothing to disclose: Bashar Amr, Nang Kham, Viral Doshi, Tareq Zaza
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