PULMONARY VEIN THROMBOSIS VISUALIZED BY ENDOBRONCHIAL ULTRASOUND (EBUS): A RARE FINDING

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Endobronchial ultrasound (EBUS) offers a minimally invasive tool to allow for visualization and histopathological diagnosis of mediastinal and hilar lymph nodes or masses. Simultaneously, it allows for visualization of major vasculature surrounding the tracheobronchial tree such as the pulmonary veins and arteries. Limited report exists regarding pulmonary vein thrombosis (PVT) visualization with EBUS with only one case being found after conducting a PubMed search. We are presenting an additional case of PVT incidentally diagnosed by chest computed tomography (CT) and later visualized by EBUS. CASE PRESENTATION: A 66-year-old female with a history of 30 pack-year smoking and COPD stage IVB, was found to have a sub-centimeter left lower lobe (LLL) nodule on lung cancer screening. CT chest with contrast was performed revealing new right and left hilar lymphadenopathy without extra-thoracic involvement. Due to claustrophobia PET scan was not tolerated. Repeat CT with contrast revealed that the presumed left hilar mass was actually an occlusive pulmonary vein thrombosis in the superior pulmonary vein. Few weeks later patient was admitted to the hospital with worsening fatigue and right side pleuritic chest pain. Exam was unremarkable. She was managed with therapeutic anticoagulation and antibiotics for possible infectious thrombosis. EBUS-transbronchial needle aspiration of station R10 revealed small cell lung carcinoma. Incidentally the pulmonary vein thrombosis visualized by EBUS (Figure1&2) and confirmed with Doppler mode was comparable with CT images. Chest CT repeated after 6 weeks showed minimal change in the PVT and the patient was continued on therapeutic enoxaparin without complication. DISCUSSION: PVT is a rare and fatal condition with non-specific presenting symptoms making diagnosis a challenge. There have been several case reports on PE diagnosis by EBUS, but to the best of our knowledge there has been only one other case report of PVT visualized on EBUS. No guidelines exist for the diagnosis of PE and PVT with EBUS and much of literature are the case reports only. We are presenting this case to demonstrate that EBUS could be an option to diagnose or confirm PVT when other modalities are contraindicated (e.g. CT pulmonary angiography in the presence of renal impairment or contrast allergy). Although EBUS visualization of PVT may not be applicable to the general population due to cost and invasiveness it could be considered as an alternative diagnostic modality in the right sub-population. CONCLUSIONS: PVT is a rare condition which could prove fatal if diagnosed late. Due to its nebulous presentation, diagnosis can be challenging. EBUS could be considered for the diagnosis or confirmation of PVT in the right sub-population. Reference #1: MacEachern P, Dang B, Stather D, Tremblay A. Tumor invasion into pulmonary vessels viewed by endobronchial ultrasound. J Bronchol 2008; 15:206–207. Reference #2: Swartz MA, Gillespie CT. Pulmonary emboli detected by endobronchial ultrasound. Am J Respir Crit Care Med 2011; 183:1569. Reference #3: Mohammad R. Al-Ajam et al. Endobronchial Ultrasound. When to Venture into the Vasculature. ll AnnalsATS Issues. Vol. 10, No. 4 | Aug 01, 2013. DISCLOSURES: No relevant relationships by Muhammad Bilal, source=Web Response No relevant relationships by Cynthia Callahan, source=Web Response No relevant relationships by Ameet Kumar, source=Web Response No relevant relationships by Benedicta Nnodum, source=Web Response