Umbilical venous catheter-related ischemia of fingers, right atrial thrombus treated with recombinant tissue plasminogen activator and lethal pulmonary hypertension in a preterm infant

Abstract

We report the second case in English literature of limb ischemia related to umbilical venous catheter (UVC) use. This case was an extremely low birth weight preterm infant who otherwise remained stable during the first 8 days of life. On day 9, she developed intermittent ischemia of the distal phalanges of four fingers on the right hand. On day 11, the ischemia worsened during obtaining a blood for culture from the UVC. Blood cultures yielded cloxacillin-sensitive Staphylococcus aureus. On day 15, a large right atrial thrombus (RAT) was found after an echocardiogram (ECHO). Through consecutive ECHOs, we determined that the RAT was increasing in size. After administering a single dose of recombinant tissue plasminogen activator, size of the RAT decreased significantly, and no anticoagulants, it was deemed unnecessary. On day 147, the patient developed pulmonary hypertension (PH), which was attributed to severe bronchopulmonary dysplasia, and the patient died on day 168. After thorough analysis of the case, it is possible that PH might have been caused by a pulmonary embolism (PE). If a long-term anticoagulant was administered, or PE was considered and treated, the final patient outcome might have been different. In summary, a diagnosis of UVC-related ischemia requires a high index of suspicion. It may be of value to administer a long-term anticoagulant after successful treatment of RAT, and it would be prudent to consider a PE in a preterm infant who then develops PH.