Pulmonary vein thrombosis secondary to tuberculosis in a non-HIV infected patient

Abstract

Tuberculosis has been suggested as an independent risk factor for thromboembolism due to a hypercoagulable state induced by changes in clotting factors, protein C and vascular endothelium. Pulmonary vein thrombosis (PVT) is a rare, potentially serious and life-threatening condition that can be caused by tuberculosis. Its rare occurrence is due to a rich network of venous collateral vessels that drain the lung. PVT can also occur following lobectomy for malignancy, lung transplantation, radiofrequency catheter ablation for atrial fibrillation, sclerosing mediastinitis and following metastatic cancer, such as liposarcoma. Pulmonary vein thrombosis is difficult to diagnose clinically and requires a combination of conventional diagnostic modalities. Systemic anticoagulation, treatment of the predisposing pathology and monitoring of the thrombosis are parts of management of pulmonary vein thrombosis. We present a case of pulmonary vein thrombosis due to tuberculosis. Our patient is a 67-year-old Caucasian male with a past medical history significant for hypertension and hyperlipidemia who came to our hospital with hemoptysis, cough and shortness of breath 1-month duration. He also noticed around 20 pounds of weight loss and night sweats but had no fever. He had no history of travel outside the USA and has never been incarcerated before, but he endorsed that his son has been in Jail before but the son has never been diagnosed with TB. He quit smoking 2 months ago. He was tachycardic, tachypneic and had decreased air entry with crepitation in the right side of the posterior chest. Chest x ray showed multiple cavitary lesions in the right upper lobe area. CT scan of the chest with contrast showed pulmonary venous partial thrombosis in the right upper lobe with multiple cavitary lesions with hilar and mediastinal lymphadenopathy. Sputum AFB was positive for mycobacterium tuberculosis and was sensitive for rifampicin. Patient was treated with systemic anticoagulation and anti-tuberculosis medications. Patient’s hospital course was complicated by development of elevated liver enzymes at which time the anti-TB medications were stopped to be restarted one by one with a follow up of his liver enzymes and liver function tests. Our case shows that presentation of patients with PVT is non-specific and needs a very high index of suspicion for proper diagnosis and management to prevent further complications as it is associated with limb and life-threatening complications. It also illustrates the importance of considering PVT in a patient with tuberculosis.