Lung Pathology |

Left Lower Extremity Weakness in a Patient With Pulmonary Arteriovenous Malformation FREE TO VIEW

Erin Liu, MD
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Santa Clara Valley Medical Center, Campbell, CA

Chest. 2015;148(4_MeetingAbstracts):620A. doi:10.1378/chest.2272075
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SESSION TITLE: Lung Pathology Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary arteriovenous malformation (PAVM) is a rare disorder characterized by abnormal communication between pulmonary veins and arteries. Patients with PAVMs often are asymptomatic and remain undiagnosed until young adulthood when complications can arise. In this case, we discuss a patient with pulmonary embolism who presented with transient left-sided weakness secondary to paradoxical embolism via PAVM.

CASE PRESENTATION: A 29 year old man with a history of pulmonary tuberculosis presented to the emergency department with acute onset of chest pain for 1 day. One week prior to admission, the patient had been hospitalized for 2 months for a right thalamic brain abscess that was complicated by ventriculitis and hydrocephalus requiring ventriculoperitoneal shunt. His exam was notable for mild tachycardia but was otherwise unremarkable. CT of the chest revealed bilateral subsegmental pulmonary emboli. Of note, while being evaluated in the ED the patient developed acute onset of dysarthria and left lower extremity weakness which completely resolved after 15 minutes. CT of the head demonstrated known right frontal ventriculostomy but was otherwise unchanged from prior. He was started on a heparin drip. Upon further review, CT of the chest also revealed a prominent arterial vascular structure with dilated veins and thrombosis within the structure consistent with left upper lobe PAVM. Given high suspicion for an embolic event, contrast echocardiogram was done which confirmed right-to-left shunt. Interventional Radiology was consulted for embolization, however given the location of the thrombus and increased risk for infarction of the LUL, this was deferred. The remainder of his hospital course was uneventful and he was discharged on Lovenox with plans for future embolization of the PAVM.

DISCUSSION: This case describes transient left lower extremity weakness as an atypical presentation of PAVM. This patient's presentation, especially with a history of recent brain abscess and new focal neurologic deficits in the setting of pulmonary emboli was very concerning for a right-to-left circulation communication and paradoxical embolus to the brain. The diagnosis of PAVM is confirmed on CT imaging. Treatment options to prevent embolic events in patients with PAVMs include embolization and surgery.

CONCLUSIONS: Although PAVMs are rare, they are treatable and should be considered in the differential diagnosis of young patients who present with symptoms of ischemic TIA or stroke, with or without concurrent venous thrombotic risk factors.

Reference #1: Shovlin, CL. “Pulmonary Arteriovenous Malformations.” Am J Respir Crit Care Med. Vol 190, Iss 11, pp 1217- 1228. Dec. 1 2014.

DISCLOSURE: The following authors have nothing to disclose: Erin Liu

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