Thrombus in a Normal Left Ventricle: A Cardiac Manifestation of Pheochromocytoma

A Rare Case of Left Ventricular Thrombus in a Normal Heart in a Patient With Factor V Leiden Disease

Left ventricular thrombus (LVT) is mostly associated with anterior wall myocardial infarction and reduced ejection fraction. It can also be associated with cardiomyopathy, myocarditis, and hypercoagulable states such as cancer, antiphospholipid syndrome, and protein C or protein S deficiency. Factor V Leiden (FVL) disease is one of the hypercoagulable states where mutant factor V is insensitive to natural anticoagulation factor protein C, and FVL disease increases the risk of peripheral thromboembolism such as pulmonary embolism (PE) and deep vein thrombosis (DVT). We report a 60-year-old female patient with a history of heterozygous factor V Leiden and a remote history of deep vein thrombosis who presented with left-sided weakness and intermittent chest pain. Computed tomography (CT) of the brain ruled out stroke, electrocardiogram (EKG) showed sinus rhythm and some new T-wave inversion, and troponin was mildly elevated. Other laboratory results were unremarkable. A transthoracic echocardiogram showed a left ventricular mass with left ventricular outflow tract (LVOT) obstruction in systole with normal systolic and diastolic function and no wall motion abnormalities. Emergent surgery proved to be a thrombus. The learning objectives of our case are that a normal-sized and functional left ventricle does not preclude left ventricular thrombosis, long-term anticoagulation therapy in patients with factor V Leiden and a first episode of thromboembolism with additional risk factors may prevent further serious thromboembolic event, and timely diagnosis and treatment of cardiac thrombosis may reduce morbidity and mortality.

Case report: Antiplatelet therapy on metastatic paraganglioma-associated cutaneous vascular disease and literature review

Context

Tumor-associated cutaneous vascular disorder induced by PPGL was extremely rare, and the cutaneous manifestations could disappear after removal of the tumors. However, the definite pathological diagnosis and the potential mechanism remained unidentified. We presented a severe cutaneous vascular lesion manifested as diffuse erythema with ulceration and necrosis over the limbs in a female patient with metastatic paraganglioma. Skin biopsy was performed on her for defining the pathological diagnosis and potential mechanism. The patient was diagnosed as vascular disease according to the obvious angioectasia in dermis on cutaneous pathology, which might be caused by PPGL-induced hypercoagulability. We used the antiplatelet therapy with aspirin to treat the PPGL-associated cutaneous vascular disease for the first time, and the cutaneous lesions were relieved and healed gradually, further supporting the diagnosis of vascular disease.

Conclusion

For metastatic PPGL patients like the case we reported, the definite diagnosis by skin biopsy and the early antiplatelet therapy might be effective to the cutaneous lesions caused by the hypercoagulable state of PPGL.

Patients with Left Ventricular Thrombus Despite Normal Systolic Function

The formation of a thrombus in the left ventricle (LV) in patients with normal systolic function is very rare. We report a case and identified 31 other adult patients who had an LV thrombus with normal LV systolic function. The median (IQR) age of these patients was 43 [37,59] years with a slight male predominance (59%). The vast majority of patients presented with embolic complications (28; 88%) with 3 of the other patients presenting with a febrile illness. Most of the cases occurred in the setting of an identifiable medical condition that carries an increased risk of thrombosis including inflammatory diseases, malignancies or hypereosinophilia. Treatment generally included anticoagulation with or without surgical removal or systemic thrombolysis. Recurrence of LV thrombus and/or embolic events have been reported in patients with LV thrombus and normal LV systolic function suggesting that long term anticoagulation may be needed.

Massive Mobile Left Ventricular Thrombus in a Patient With Normal Left Ventricular Systolic Function

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Left ventricular thrombi (LVT) formation is associated with impaired LVEF.

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LVT are extremely rare among patients with normal ejection fraction.

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LVT may be clinically silent but may also present with embolization.

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Cardiac magnetic resonance is the gold standard noninvasive test to diagnose LVT.

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Large LVT are preferably treated with surgical excision.

Paraganglioma as a rare cause of left ventricular thrombus in the setting of preserved ejection fraction: discussing the literature

Paragangliomas and pheochromocytomas are catecholamine-secreting tumours which if remain undiagnosed may cause severe morbidity and mortality. In rare circumstances these tumours can cause left ventricular (LV) thrombi to form by inducing cardiomyopathy and subsequent embolic complications. After a thorough literature review, six previous cases were found that presented the formation of an LV thrombus in the setting of a pheochromocytoma or paraganglioma. A majority of these cases were associated with significant wall motion abnormalities and their cardiac ejection fraction (EF) was compromised. This is a rare case of a patient developing LV thrombi in the setting of a paraganglioma with normal cardiac EF. We present this case to compare the similarities and differences of our case with previously reported cases and emphasise the importance of suspecting these LV thrombi in patients with these neuroendocrine tumours.

Acute upper extremity arterial thrombosis and stroke in an unresected pheochromocytoma

Pheochromocytoma is a rare cause of hypertension in the general population. Only isolated reports show an association with acute obstructive arterial thrombosis. A 50-year-old chronically noncompliant woman with a known unresected pheochromocytoma presented to the emergency department with ataxia. Imaging confirmed a right-sided ischemic stroke. During her hospital stay, the patient developed signs consistent with acute right upper extremity ischemia resulting from occlusion in the distal right subclavian, axillary, and proximal brachial arteries. Emergent open thrombectomy was successfully performed. In patients with an unresected pheochromocytoma, one must consider acute arterial thrombosis as a rare but potentially limb-threatening and even life-threatening complication.