PULMONARY VTE CAUSING ACUTE ISCHEMIC LIMB

Abstract

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary vein thrombosis is a rare entity with severe possible complications. Here we present the case of a 62 y/o female who presented with pneumonia and diabetic ketoacidosis (DKA) and was subsequently found to have an ischemic left lower extremity due to an embolic pulmonary venous thromboembolism (PVT). CASE PRESENTATION: A 62 year old female with a history of diabetes mellitus type 2 presented with altered mental status. She was admitted to the medical intensive care unit for DKA and severe sepsis due to a left lower lobe cavitary pneumonia. Her sputum culture speciated Methicillin Resistant Staph Aureus (MRSA) and Acinetobacter treated with Vancomycin and Zosyn, respectively. Her cavitation was presumed to be secondary to her MRSA pneumonia. Her hospital course was complicated by the development of acute ischemia of her left lower extremity due to an arterial thrombus in the left popliteal artery. A heparin infusion was then started and she was emergently taken to interventional radiology for angiography, mechanical thrombectomy and intraarterial thrombolysis with catheter directed tissue plasminogen activator. On further evaluation of patient's arterial occlusion, she was also found to have a right lower lobe subsegmental pulmonary embolism and left superior pulmonary venous thrombosis. Unfortunately, due to underlying severe peripheral arterial disease, her limb became non-viable and a below the knee amputation was performed. The etiology of PVT was presumed to be due to an overwhelming inflammatory response to her necrotizing pneumonia after hematologic workup revealed no evidence of disseminated intravascular coagulation or heparin induced thrombocytopenia. She was eventually transitioned to Apixaban later in her hospital course and discharged to inpatient rehabilitation with plans for outpatient hypercoagulable workup. DISCUSSION: PVT is a rare entity, with even more rare complications. The pulmonary vein is the most proximal source of arterial thromboembolism. Known etiologies of PVT are malignancy, post lung surgery, hypercoagulable state, or idiopathic. Diagnosis of PVT can be a challenge requiring CT angiography and echocardiography. Delay in diagnosis can lead to severe complications including pulmonary infarction, edema, right ventricular failure, or peripheral embolization as seen in our case. As far as we can tell there is no other documented case report of non-lung surgery related PVT associated with acute limb ischemia. Treatment requires systemic anticoagulation however little is known about the optimal duration or rate of recurrence. CONCLUSIONS: Although very rare, patients with acute limb ischemia need to have timely management and evaluation for etiology. In this case, the patient was successfully treated with Apixaban after limb amputation. This is an interesting case due to its rarity and demonstrates importance of identifying and treating this disease process. Reference #1: Barreiro TJ, Kollipara VK, Gemmel DJ. Idiopathic pulmonary vein thrombosis?. Respirol Case Rep. 2017;6(1):e00277. Published 2017 Oct 24. doi:10.1002/rcr2.277 Reference #2: Inoue S, Kuma S, Ohga T, Tokuishi K, Okabayashi K. Acute limb ischemia of the lower extremity associated with left upper lobe surgery for primary lung cancer. J Vasc Surg Cases Innov Tech. 2018;4(2):83-86. Published 2018 Apr 14. doi:10.1016/j.jvscit.2017.12.013 Reference #3: Nnodum BN, Manjunath M, Kumar A, Makdisi T. Spontaneous idiopathic pulmonary vein thrombosis successfully treated with Warfarin: A case report and review of the literature. Respir Med Case Rep. 2019;26:296-298. Published 2019 Feb 22. doi:10.1016/j.rmcr.2019.02.020 DISCLOSURES: No relevant relationships by Kevin Green, source=Web Response No relevant relationships by Christopher Izzo, source=Web Response No relevant relationships by Spencer Streit, source=Web Response