Unusual Cause of Acute Pulmonary Embolism: Giant Hepatic Hemangioma

Abstract

Introduction: Giant hepatic hemangioma, characterized as cavernous hemangiomas larger than 4 cm in diameter, may cause various symptoms or complications depending on the size, location and the degree of compression on adjacent structures. Pulmonary emboli (PE) may occasionally arise from deep vein thrombosis (DVT) in less common locations including inferior vena cava (IVC). IVC thrombosis is a rare entity, and may result from external compression of IVC by giant hepatic hemangioma. Case Presentation: A 53-year-old African American man presented with a 3-day history of worsening shortness of breath, pleuritic chest pain and hemoptysis. On admission, the patient was hemodynamically stable. Physical examination revealed diffuse abdominal tenderness and hepatomegaly. Past medical history was remarkable for hypertension. He drank alcohol daily and reported recreational drug abuse. He reported no recent surgery or immobilization, prior venous thromboembolic event, or family history of hypercoagulability. Computed tomography (CT)angiogram of the chest showed bilateral segmental PE in the upper lobes, right middle lobe, and lower lobes. Contrast-enhanced CT scanning of the abdomen revealed two large low density lesions in the liver, one in segment IV measuring approximately 15.3 x 13 cm in size and another in segment VIII measuring 9 x 13.8 cm in size. There was peripheral nodular puddling with enhancement slowly filling in towards the center, becoming increasingly isodense at the periphery on the delayed scan, suggestive of giant cavernous hemangioma. The diagnosis was confirmed with magnetic resonance imaging. Hepatic Doppler ultrasound (US) revealed a filling defect in the center of the retrohepatic IVC with high blood velocities adjacent to the region. Color Doppler US of the lower extremities did not reveal DVT. Surgical resection and enucleation was not possible in this case due to large and multiple lesions that occupied nearly all the liver. Anticoagulation with warfarin was initiated due to bilateral PE and IVC thrombus. Discussion: Selective compression of IVC by giant hepatic hemangioma may have caused thrombosis in the IVC leading to pulmonary embolism. Another possible mechanism is the migration of thrombi from the hemangioma itself to the hepatic veins and IVC. This case highlights the importance of detailed abdomen work-up in acute pulmonary emboli, particularly in patients with PE without evidence of DVT of lower extremity.Figure 1Figure 3