An abnormal venous clot

Abstract

A 47-year-old Caucasian man, previously well, was admitted to hospital in July, 1996, with a 9 day history of painful swelling of his left lower leg. He was a non-smoker and had no risk factors for venous thrombosis. On examination he had a swollen left leg with minimal tenderness and no other abnormal findings. Deep venous thrombosis (DVT) was confirmed by venography, which showed a welldemarcated filling defect in the left femoral vein thought to represent a localised thrombus (figure). Chest radiograph was normal. He was anticoagulated with warfarin for 6 months, with the INR maintained between 2·0 and 3·0. Review in the clinic, however, showed little clinical improvement in his condition. Doppler ultrasound scans were consistent with the previous venogram. Abdominal and pelvic ultrasound scans were normal. His mobility did not improve over the next 2 years because of persistent swelling of his left leg, but he was otherwise asymptomatic. Venography in 1998 again showed a localised filling defect, thought to represent persistent thrombus, with the development of collateral venous network. A Palma surgical venous bypass procedure to improve venous drainage in the affected limb was done in 1999 at which localised thrombus was noted in the common femoral vein with normal surrounding structures. No chest radiograph was done preoperatively since he had no respiratory symptoms but a post-operative mobile chest radiograph to confirm correct placement of a central venous catheter suggested a right hilar mass. There was a decrease in the leg swelling post-operatively. Subsequently, he had a haemoptysis. Further chest radiographs showed a mass overlying the right lung hilum with several pulmonary nodules scattered throughout both lung fields. The appearances suggested metastatic disease; computed tomography (CT) scan of thorax supported this. Bronchoscopy (including histology on biopsy samples) was normal but a biopsy sample from a pulmonary nodule showed a malignant spindle-cell tumour possibly of vascular origin. Magnetic resonance CASE REPORT