Lung Cancer: Student/Resident Case Report Poster - Lung Cancer I |

Internal Jugular Vein Thrombosis: An Unusual Presentation of Lung Cancer FREE TO VIEW

Coral Olazagasti, MD; Mariana Mercader, MD; Sarun Thomas, DO; Jason Steinberg, MD; Eve Merrill, MD
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Mount Sinai Beth Israel, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):742A. doi:10.1016/j.chest.2016.08.837
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SESSION TITLE: Student/Resident Case Report Poster - Lung Cancer I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Thromboses of the upper extremity and neck are rare and not as common as lower extremity DVTs. Internal jugular vein thrombosis (IJVT) is a serious event with a potentially fatal outcome. IJVT is most frequently associated to central venous catheterization and IV drug use. Other etiologies, such as hypercoagulability and occult or known malignancy, are not well described in the literature.

CASE PRESENTATION: A 35 y/o male with a history of prior tobacco use and occasional cocaine use presented with right-sided neck swelling and vein distention for three days. He denied trauma, fever, or chills. Vital signs were normal. Physical examination was remarkable for bulging right neck veins and swelling extending to the shoulder. Initial labs were significant for WBC 12.4 K/uL and D-dimer 4.66 ug/mL. CT angiogram of the head and neck showed acute thrombosis of the right internal jugular vein. He was started on systemic anticoagulation with enoxaparin. CT of the chest/abdomen/pelvis revealed a cavitary mass in the right lower lobe, enlarged nodes in right hilum and hypodense masses on the liver and right kidney, suggestive of widespread metastatic disease. Scrotal ultrasound was normal. IR-guided biopsy of the liver masses was positive for metastatic poorly differentiated adenocarcinoma with signet ring cell features. Immunostaining revealed that the tumor was positive for TTF-1, CK7, and CK20 suggesting primary lung origin. CDX-2, a highly specific marker for intestinal adenocarcinoma, was negative. MRI of the brain was negative for metastasis and endoscopy and colonoscopy did not reveal suspicious lesions. Patient was discharged on anticoagulation and started on carboplatin and paclitaxel for stage IV lung cancer.

DISCUSSION: The history and physical examination of patients with an IJVT may be vague and misleading. Patients may present with a painful swelling of the neck but they may also be absolutely asymptomatic. Diagnosis by Doppler ultrasound or CT imaging is a necessity in order to make a rapid diagnosis and prevent fatal complications.

CONCLUSIONS: This case demonstrates that internal jugular vein thrombosis is an unusual but possible initial presentation of metastatic lung cancer. Although the incidence is unknown, IJVT’s can lead to the development of pulmonary embolisms, sepsis with septic emboli to different organs, as well as intracranial propagation of the thrombus with cerebral edema. Treatment with anticoagulation should be initiated to prevent sequelae and worsening of symptoms. In the absence of recent instrumentation of the upper extremity vasculature, other causes such as hypercoagulable states should be explored.

Reference #1: C. C. Boedeker, G. J. Ridder, et al. Etiology and Therapy of the Internal Jugular Vein Thrombosis. Laryngo-Rhino-Otol 2004; 83(11): 743-749 DOI: 10.1055/s-2004-825749

Reference #2: Hylton V. Joffe, Nils Kucher, et al. Upper-Extremity Deep Vein Thrombosis. September 21, 2004DOI: 10.1161/ 01.CIR.0000142289.94369.D7

DISCLOSURE: The following authors have nothing to disclose: Coral Olazagasti, Mariana Mercader, Sarun Thomas, Jason Steinberg, Eve Merrill

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