AN EVANESCENT RIGHT ATRIAL MASS FROM CATHETER-RELATED THROMBOSIS

Abstract

SESSION TITLE: Cardiovascular Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: A diagnosis of catheter-related upper extremity deep vein thrombosis (CRUE-DVT) should be considered in the differential for right atrial mass in a patient with history of malignancy and presence of peripherally inserted central catheter (PICC) because the pulmonary embolism (PE) can be fatal even with anticoagulation.[1] CASE PRESENTATION: A 34 year old male with a history of diabetes mellitus, chronic kidney disease, testicular cancer status post orchiectomy with mediastinal metastatic seminoma resection, and intravenous drug use, presented with acute encephalopathy. He was admitted for diabetic ketoacidosis secondary to sepsis from osteomyelitis of his right foot and found to have MRSA bacteremia and candida glabrata fungemia. The patient continued to improve clinically until he developed acute hypoxic respiratory failure requiring ventilator support several days after admission. Physical exam was notable for tense right upper extremity at site of PICC without erythema or tenderness. Laboratory studies were notable for WBC of 21.5 with neutrophilia, and MRSA from right foot abscess culture and blood cultures. CT of thorax revealed extensive diffuse bilateral groundglass opacities with intralobular thickening and areas of consolidation, concerning for aggressive acute interstitial pneumonia. Bronchoalveolar lavage showed mildly elevated eosinophilia suggestive of eosinophilic pneumonia, for which the patient was treated with corticosteroids. A critical care transesophageal echocardiogram (TEE) was performed to evaluate for endocarditis and revealed a small gelatinous appearing mass contiguous with right atrial wall at the entrance of superior vena cava and interatrial shunt with suspected patent foramen ovale (Figure 1-3). Right upper extremity venous duplex ultrasonography showed completely thrombosed right basilic, brachial, axillary, and subclavian veins likely catheter-related with thrombus extension to right atrium.PICC was removed for concern of right atrial thrombus infection and anticoagulation was started. The repeat TEE performed 10 days later did not reveal a right atrial mass. The patient left the hospital against medical advice, with a therapeutic international normalized ratio but returned within 24 hours following a cardiac arrest. CT thorax angiography revealed PE with right ventricular strain, and the patient expired 48 hours later, with anoxic brain injury noted following resuscitation. DISCUSSION: CRUE-DVT should be considered with an evanescent right atrial mass, and a duplex ultrasonography should be considered because incidence of PE can be as high as 36 percent in patients with malignancy.[2,3] Optimal therapy is unknown although anticoagulation and infection-driven catheter removal appear to be the first line therapy. CONCLUSIONS: CRUE-DVT patients with ASD can develop PE and paradoxical arterial embolism, which can prove fatal, even with anticoagulation. Reference #1: Monreal M et al. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines--a prospective study. Thromb Haemost. 1994;72(4):548. Reference #2: Muñoz FJ et al. Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. Chest. 2008;133(1):143. Reference #3: Prandoni P et al. Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med. 1997;157(1):57. DISCLOSURES: No relevant relationships by Michel Boivin, source=Web Response No relevant relationships by Chih-Wei Chang, source=Web Response No relevant relationships by Nicholas Villalobos, source=Web Response