CAVITARY PNEUMONIA: THE CLOT THICKENS

Abstract

SESSION TITLE: Thrombus NightmaresSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: Pulmonary Vein Thrombosis (PVT) is a lethal source of thromboembolism. It is uncommon, reported largely in case reports. It is seen in patients with a history of lung malignancy, lobectomy/lung transplant, RFCA for atrial fibrillation, mitral stenosis, atrial myxoma. Complications include RV failure, limb ischemia, renal and pulmonary infarction.CASE PRESENTATION: A 64-year-old male presented with subjective fevers, chills, unintentional weight loss, decreased appetite, shortness of breath and cough with sputum production. No hemoptysis, incarceration, or travel outside the US. He had a medical history of COPD, a 42 pack year smoking history and alcohol use. He was found to be in respiratory distress, his oxygen saturation being 70%. His vitals were otherwise stable. He appeared chronically ill, tachypneic with accessory muscle use, had decreased breath sounds bilaterally with crackles present in left lower lung fields. There was no JVD, lower extremity edema, murmurs, or arrhythmias. His labs showed lactic acidemia of 5.5 mmol/l. A viral pneumonia PCR was negative. A CXR showed left upper lobe pneumonia with areas of cavitation. CTA of the chest showed a large thrombus in the left pulmonary vein, a large cavitary process in the left lung w/ multifocal ground glass and nodular opacities. There was occlusion of multiple left lower lobar and lingular bronchi. He was started on broad spectrum antibiotics and therapeutic anticoagulation with heparin. Testing for HIV, immunology for cANCA, pANCA, myeloperoxidase antibody, AFB stain x 1 and blood cultures negative. Sputum cultures positive for MSSA. Lower extremity venous duplex was negative for DVT. A TTE was negative for mitral stenosis. The patient transitioned to supplemental oxygen via nasal canula at 2 lpm. However, on HD#3, the patient developed acute mental status changes and suffered a PEA cardiac arrest. Code status was DNR and patient passed.DISCUSSION: PVT remains rare due to the rich network of collateral vessels that drain the lung. Many patients are asymptomatic although they may exhibit dyspnea, cough, or hemoptysis. The patient's risk factors for developing primary lung cancer and subsequent PVT included history of tobacco use and a family history significant for lung cancer. The patient's respiratory status improved with initial systemic anticoagulation. Unfortunately, it appears as though the patient suffered a systemic thromboembolism resulting in a CVA. Further considerations would have included bronchoscopy for evaluation of possible underlying malignancy and further testing for underlying hyper-coagulable state. Additionally, reports have indicated resolution of idiopathic PVT after therapeutic anticoagulation, which would be a consideration in this patient.CONCLUSIONS: Regardless of its low incidence it should be in the differential for patients presenting with non specific constitution of symptoms as outlined above.Reference #1: Cavaco, R.A., Kaul, S., Chapman, T. et al. Idiopathic pulmonary fibrosis associated with pulmonary vein thrombosis: a case report. Cases Journal 2, 9156 (2009). https://doi.org/10.1186/1757-1626-2-9156Reference #2: Chaaya G, Vishnubhotla P. Pulmonary Vein Thrombosis: A Recent Systematic Review. Cureus. 2017;9(1):e993. Published 2017 Jan 23. doi:10.7759/cureus.993Muhammad Asim Rana, Nicholas Tilbury, Yashwant Kumar, Habib Ahmad, Kamal Naser, Ahmed F. Mady, Awani Patel, "Idiopathic Pulmonary Vein Thrombus Extending into Left Atrium: A Case Report and Review of the Literature", Case Reports in Medicine, vol. 2016, ArticleReference #3: Muhammad Asim Rana, Nicholas Tilbury, Yashwant Kumar, Habib Ahmad, Kamal Naser, Ahmed F. Mady, Awani Patel, "Idiopathic Pulmonary Vein Thrombus Extending into Left Atrium: A Case Report and Review of the Literature", Case Reports in Medicine, vol. 2016, Article ID 3528393, 3 pages, 2016. https://doi.org/10.1155/2016/3528393Sandeep Sahay, Robert Lodato, Pulmonary Vein Thrombosis: A Rare Entity,Chest,Volume 144, Issue 4, Supplement, 2013,Page 129A,SSN 0012-3692, https://doi.org/10.1378/chest.1705212.DISCLOSURES: No relevant relationships by Brandon HoweNo relevant relationships by Prerna SharmaNo relevant relationships by Kevin Smith SESSION TITLE: Thrombus Nightmares SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pulmonary Vein Thrombosis (PVT) is a lethal source of thromboembolism. It is uncommon, reported largely in case reports. It is seen in patients with a history of lung malignancy, lobectomy/lung transplant, RFCA for atrial fibrillation, mitral stenosis, atrial myxoma. Complications include RV failure, limb ischemia, renal and pulmonary infarction. CASE PRESENTATION: A 64-year-old male presented with subjective fevers, chills, unintentional weight loss, decreased appetite, shortness of breath and cough with sputum production. No hemoptysis, incarceration, or travel outside the US. He had a medical history of COPD, a 42 pack year smoking history and alcohol use. He was found to be in respiratory distress, his oxygen saturation being 70%. His vitals were otherwise stable. He appeared chronically ill, tachypneic with accessory muscle use, had decreased breath sounds bilaterally with crackles present in left lower lung fields. There was no JVD, lower extremity edema, murmurs, or arrhythmias. His labs showed lactic acidemia of 5.5 mmol/l. A viral pneumonia PCR was negative. A CXR showed left upper lobe pneumonia with areas of cavitation. CTA of the chest showed a large thrombus in the left pulmonary vein, a large cavitary process in the left lung w/ multifocal ground glass and nodular opacities. There was occlusion of multiple left lower lobar and lingular bronchi. He was started on broad spectrum antibiotics and therapeutic anticoagulation with heparin. Testing for HIV, immunology for cANCA, pANCA, myeloperoxidase antibody, AFB stain x 1 and blood cultures negative. Sputum cultures positive for MSSA. Lower extremity venous duplex was negative for DVT. A TTE was negative for mitral stenosis. The patient transitioned to supplemental oxygen via nasal canula at 2 lpm. However, on HD#3, the patient developed acute mental status changes and suffered a PEA cardiac arrest. Code status was DNR and patient passed. DISCUSSION: PVT remains rare due to the rich network of collateral vessels that drain the lung. Many patients are asymptomatic although they may exhibit dyspnea, cough, or hemoptysis. The patient's risk factors for developing primary lung cancer and subsequent PVT included history of tobacco use and a family history significant for lung cancer. The patient's respiratory status improved with initial systemic anticoagulation. Unfortunately, it appears as though the patient suffered a systemic thromboembolism resulting in a CVA. Further considerations would have included bronchoscopy for evaluation of possible underlying malignancy and further testing for underlying hyper-coagulable state. Additionally, reports have indicated resolution of idiopathic PVT after therapeutic anticoagulation, which would be a consideration in this patient. CONCLUSIONS: Regardless of its low incidence it should be in the differential for patients presenting with non specific constitution of symptoms as outlined above. Reference #1: Cavaco, R.A., Kaul, S., Chapman, T. et al. Idiopathic pulmonary fibrosis associated with pulmonary vein thrombosis: a case report. Cases Journal 2, 9156 (2009). https://doi.org/10.1186/1757-1626-2-9156 Reference #2: Chaaya G, Vishnubhotla P. Pulmonary Vein Thrombosis: A Recent Systematic Review. Cureus. 2017;9(1):e993. Published 2017 Jan 23. doi:10.7759/cureus.993 Muhammad Asim Rana, Nicholas Tilbury, Yashwant Kumar, Habib Ahmad, Kamal Naser, Ahmed F. Mady, Awani Patel, "Idiopathic Pulmonary Vein Thrombus Extending into Left Atrium: A Case Report and Review of the Literature", Case Reports in Medicine, vol. 2016, Article Reference #3: Muhammad Asim Rana, Nicholas Tilbury, Yashwant Kumar, Habib Ahmad, Kamal Naser, Ahmed F. Mady, Awani Patel, "Idiopathic Pulmonary Vein Thrombus Extending into Left Atrium: A Case Report and Review of the Literature", Case Reports in Medicine, vol. 2016, Article ID 3528393, 3 pages, 2016. https://doi.org/10.1155/2016/3528393 Sandeep Sahay, Robert Lodato, Pulmonary Vein Thrombosis: A Rare Entity,Chest,Volume 144, Issue 4, Supplement, 2013,Page 129A,SSN 0012-3692, https://doi.org/10.1378/chest.1705212. DISCLOSURES: No relevant relationships by Brandon Howe No relevant relationships by Prerna Sharma No relevant relationships by Kevin Smith