A MISCARRIAGE THAT METASTASIZES: A CASE OF CHORIOCARCINOMA IN THE ICU

Abstract

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Gestational trophoblastic neoplasia (GTN) is a rare oncologic emergency that requires rapid treatment. Complications can be numerous based on sites of metastasis. We present a young patient with significant disease burden and numerous complications requiring multiple aspects of critical care. CASE PRESENTATION: A 19-year-old female presented to the emergency department with 3 weeks of cough and dyspnea. 4 months prior she had a spontaneous abortion with 4 weeks of abnormal uterine bleeding. At an outside hospital she was noted to have multiple metastatic lesions with a β-HCG of 1.6 million and was transferred to our hospital for evaluation by gynecologic oncology. On presentation she was tachycardic and noted to have abdominal distension. Labwork showed sodium 131, hemoglobin 8.7, and β -HCG >850,000. Outside hospital CT chest/abdomen/pelvis showed innumerable pulmonary lesions, large necrotic mediastinal mass, pericardial effusion without tamponade, metastases in the liver, spleen, kidneys, and massive ovaries. CT of the head with lesions in the right parietal and frontal lobes with edema. She was admitted to gynecologic oncology and started chemotherapy and whole brain radiation. On hospital day 4 she was intubated for altered mental status and hypoxia. Prior to intubation she reported a headache, and afterwards had fixed and dilated pupils. CT head showed hemorrhage of brain lesions and she had emergent hemicraniectomy. Post-procedure she required multiple vasopressors; bedside echocardiogram showed known pericardial effusion without tamponade. She developed significant metabolic acidosis with renal failure and started urgent renal replacement therapy. On ICU day 4 her left hand was cool with nonpalpable pulses. CT angiography showed radial artery occlusion and she underwent decompressive surgery and radial artery dissection by surgery. After surgery, she remained intubated for an additional 7 days before being extubated. She was discharged to rehab after 49 days of hospitalization, eventually completing chemotherapy as an outpatient. DISCUSSION: GTN is a rare malignancy with the most common subtype being choriocarcinoma, which is known for rapid spread and progression. It is hallmarked by extremely elevated beta-HCG with diffuse metastatic disease. Symptoms of GTN are dependent on organs affected. It is considered an oncologic emergency requiring urgent treatment to avoid permanent injury. Classically GTN was a terminal diagnosis but is now considered a highly curable. Our patient had multiple sequelae from the metastatic spread of her disease but was successfully extubated and completed chemotherapy. CONCLUSIONS: This case details the course of a patient with a primary diagnosis that is rarely encountered in critical care medicine. She had multiple complications that required aggressive critical care in a timely fashion and was able to be discharged home with an overall good outcome. Reference #1: Smith, H.O. (2003) 'Gestational trophoblastic disease epidemiology and trends', Clinical Obstetrics and Gynecology, 46(3), pp. 541. Reference #2: Bakri, Y.N., Berkowitz, R.S., Khan, J., Goldstein, D.P., von Sinner, W., Jabbar, F.A. (1994) 'Pulmonary metastases of gestational trophoblastic tumor. Risk factors for early respiratory failure', Journal of Reproductive Medicine, 39(3), pp. 175. Reference #3: Onal, O., Salman E., Yetisir, F., Kilic, M. (2015) 'Hand ischaemia after radial artery cannulation', BMJ Case Report, bcr2015211145 DISCLOSURES: No relevant relationships by Morium Akthar, source=Web Response No relevant relationships by Alfred Lardizabal, source=Web Response No relevant relationships by Timothy Roedder, source=Web Response