Lower extremity deep venous thrombosis with fatal pulmonary thromboembolism caused by benign pelvic space-occupying lesions--an overview

Forensic considerations in nonthrombotic pulmonary embolism: A case report and review

Nonthrombotic pulmonary embolism is defined as the partial or total occlusion of the pulmonary circulation by various nonthrombotic agents, such as biological, nonbiological and foreign body material. A case is reported of lethal embolism of fragments of a renal calculus: A 64-year-old woman collapsed and died following laser lithotripsy. At autopsy calculous debris was found in the calyces of the right kidney with widespread microscopic fragments of birefringent foreign material in keeping with renal calculus within the pulmonary arterioles. Death was due to pulmonary calculus embolism complicating lithotripsy of a right renal calculus. Review of other causes of nonthrombotic pulmonary embolism revealed fat, bone marrow, amniotic fluid, trophoblast, tumours, septic material, hydatid cysts, bone, soft tissue/organ parenchyma, gastrointestinal tract contents/bile, gas, and foreign material that was introduced iatrogenically and non-iatrogenically. All of these possibilities should be considered at autopsy in the appropriate setting, with pulmonary microscopy often being essential to establishing the diagnosis.

Lethal septic pulmonary thromboembolism in a repatriated body - a rare complication of prolonged urinary catheterization

A case of septic pulmonary thromboembolism arising from thrombophlebitis of the prostatic venous plexus associated with long-term urinary catheterisation in a 51-year-old man is reported. Despite a previous autopsy having been conducted in the country where he had been resident overseas, a re-examination showed histological evidence of mild patchy chronic prostatitis with a florid, focally purulent, thrombophlebitis of the periprostatic venous plexus with abscess formation and evidence of bacterial overgrowth. Corresponding microscopy of the lungs showed septic microthromboemboli within small pulmonary arteries with variable degrees of necrotising acute inflammation and thrombosis. Death was not due to 'acute pulmonary oedema' as had been originally certified but to septic thromboembolism. This case demonstrates the need to carefully evaluate the prostatic venous plexus at autopsy, and also the type of problems that may arise at the time of the re-examination of repatriated remains.

Unusual Causes of Death Due to Constipation

ABSTRACT

Constipation is found in individuals with intellectual disabilities, autism, and cerebral palsy. Although generally a benign condition, it may lead to life-threatening intestinal obstruction, with or without volvulus, or to stercoral ulceration with enteritis and/or perforation. Two unusual cases of lethal chronic constipation are reported to demonstrate other very rare fatal mechanisms that may occur. Case 1: A 17-year-old male with cerebral palsy and autism was found deceased in bed. Death was due to pulmonary thromboembolism arising from compression of pelvic veins by acquired megacolon due to constipation (fecal mass 4.6 kg). Case 2: A second 17-year-old male with intellectual disability, global developmental delay, attention deficit disorder, seizures, and hypotonia collapsed and died during a medical evacuation from a remote community. Death was due to abdominal compartment syndrome in the context of medical air transport (medical retrieval), chronic constipation with acquired megacolon and megarectum (fecal mass 6.5 kg), global developmental delay, intellectual disability, and a suspected underlying genetic syndrome. These cases demonstrate that individuals with constipation may present for medicolegal assessment following sudden collapse/death and that pulmonary thromboembolism and abdominal compartment syndrome should be considered as rare possibilities in the evaluation of vulnerable individuals.

Large uterine fibroid causing DVT and PE: Successful management with mechanical aspiration thrombectomy and hysterectomy: A case report and literature review

RATIONALE

Uterine leiomyomas, though commonly benign, can occasionally lead to serious complications, including deep vein thrombosis (DVT) and pulmonary embolism (PE). This study aims to highlight the uncommon yet serious association between large uterine leiomyomas and thromboembolism, which is often overlooked in patients without traditional risk factors. It emphasizes the need for awareness, early diagnosis, and timely intervention to prevent complications in patients presenting with unexplained symptoms and pelvic masses.

PATIENT CONCERN

A 38-year-old gravida 5, para 2 woman presented to the emergency room with left lower extremity swelling, pain, and discoloration, accompanied by dyspnea. She had no prior history of DVT or PE and did not have any known risk factors for venous thromboembolism.

DIAGNOSIS

The patient was diagnosed with DVT and PE, confirmed by venous duplex ultrasound and abdominal and pelvic computed tomography, which revealed thrombus extension to the left iliac vein. Chest computed tomography angiography confirmed a partially occlusive thrombus in the pulmonary arteries.

INTERVENTION

The patient underwent mechanical aspiration thrombectomy, followed by placement of a left iliac stent. Anticoagulation therapy with heparin was initiated post-thrombectomy. On the third day, a right supracervical hysterectomy was successfully performed. After surgery, anticoagulation was continued with heparin, and the patient was later discharged on apixaban for ongoing therapy.

OUTCOMES

The patient made full recovery with no recurrence of thromboembolic events at 11 months posttreatment.

LESSONS

This case highlights the rare but serious complication of DVT and PE in patients with uterine leiomyomas. Timely intervention with thrombectomy, stent placement, and hysterectomy was effective in resolving the thromboembolic events.

Pulmonary Thromboemboli Due to Leiomyoma

ABSTRACT

Uterine leiomyomas are the most common pelvic tumor in women and the most frequent indication for hysterectomy. Although benign lesions, leiomyomas can cause dysfunctional uterine bleeding, pelvic pain or discomfort, infertility, and spontaneous abortion. Despite the fact that uterine leiomyomas can result in a significant amount of morbidity, it is relatively rare for these common tumors to lead to death. Here we present a case of fatal pulmonary thromboembolism that occurred due to pelvic vein thrombosis in the setting of leiomyomas.

An autopsy case of massive pulmonary tumor embolism due to undiagnosed prostatic adenocarcinoma

Adenocarcinoma of the prostate is occasionally associated with pulmonary embolism, occurring as a result of secondary hypercoagulable states or cancer-associated emboli. The objective of this study was to provide a review of clinical, histopathological and immunohistochemical features of poorly differentiated prostatic adenocarcinoma, emphasizing the relevance of undiagnosed malignancy as a cause of pulmonary embolism. The current study describes the case of a 78-year-old male who experienced remarkable clinical symptoms suggestive of pulmonary embolism. Following several diagnostic examinations, the patient was diagnosed with pulmonary embolism, which led to the detection of prostatic adenocarcinoma. Poorly differentiated adenocarcinoma with a Gleason's score of nine was set as a definite diagnosis. Multiple tumor emboli within small and medium-sized pulmonary blood vessels were found in all specimens taken from lung tissue. Immunohistochemical analysis showed diffuse and strong positivity of tumor cells within pulmonary arteries. Hidden malignancy is a diagnostic challenge that should be considered in the differential diagnosis of pulmonary embolism. Laboratory and radiological findings with additional histopathological evaluation are needed for the definite diagnosis.

Case series of seven women with uterine fibroids associated with venous thromboembolism and chronic thromboembolic disease

Uterine fibroids have been described as an associate to acute venous thromboembolism (VTE), with case reports showing an association between large uterine fibroids, acute deep venous thrombosis (DVT), and acute pulmonary embolism (PE). However, there is little known about the association or causation between uterine fibroids, chronic thromboembolic disease (CTED), and chronic thromboembolic pulmonary hypertension (CTEPH). We report on six women with uterine fibroids and CTEPH, as well as one woman with CTED, all of whom presented with exertional dyspnea, lower extremity swelling, and in the cases of CTEPH, clinical, echocardiographic, and hemodynamic evidence of pulmonary hypertension and right heart failure. Compression of the pelvic veins by fibroids was directly observed with invasive venography or contrast-enhanced computed tomography in five cases. All seven women underwent pulmonary thromboendarterectomy (PTE) followed by marked improvement in functional, clinical, and hemodynamic status.

Deep venous thrombosis, pulmonary embolism and long-distance flights

Deep vein thrombosis resulting in lethal pulmonary thromboembolism is not-infrequently encountered in forensic cases. Predisposing factors include immobility, recent surgery, previous deep venous thromboses/pulmonary thromboembolism, indwelling central venous lines, major trauma, the oral contraceptive pill, pregnancy, congenital cardiac disease, sepsis, malignancy, systemic lupus erythematosus, renal failure and certain inherited thrombophilias. Venous thrombosis associated with air travel was reported in the early 1950's and called the "economy class syndrome", although it is now recognized that reduced movement on long distance flights is more significant than seating class. Long-distance flights of eight hours or more are associated with a two to fourfold increase in the risk of deep venous thrombosis, but only in those individuals who have underlying risk factors. With increasing numbers of flights of more than 16 h duration forensic pathologists are well placed to monitor the potential impact of extended flying on the incidence of lethal pulmonary thromboembolism.

Should Prophylactic Anticoagulation Be Considered with Large Uterine Leiomyoma? A Case Series and Literature Review

Introduction. Uterine leiomyomas, also called uterine fibroids or myomas, are the most common pelvic tumors in women. They are very rarely the cause of acute complications. However, when complications occur they cause significant morbidity and mortality. Thromboembolic disease has been described as a rare complication of uterine leiomyomas. DVT is a serious illness, sometimes causing death due to acute PE. Cases. We report a case series of 3 patients with thromboembolic disease associated with uterine leiomyoma at Hurley Medical Center, Flint, Michigan, during 2015 and conduct a literature review on the topic. A literature search was conducted using Medline, PubMed, and PMC databases from 1966 to 2015. Conclusion. The uterine leiomyoma is a very rare cause of PE and only few cases have been reported. DVT secondary to uterine leiomyoma should be considered in a female presenting with abdominal mass and pelvic pressure, if there is no clear common cause for her symptoms. Thromboembolic disease secondary to large uterine leiomyoma should be treated with acute stabilization and then hysterectomy. Prophylactic anticoagulation would be beneficial for lowering the risk of VTE in patients with large uterine leiomyoma.

Bleeding versus Clotting: A Complex Case of a Large Fibroid Uterus Causing Menorrhagia and a DVT

A 43-year-old woman presented with severe anaemia secondary to menorrhagia. Pelvic ultrasound showed a large intramural posterior fundal fibroid. Hysteroscopy showed the fibroid distorting the endometrial cavity, precluding Mirena® device insertion. As she was initially hesitant to have a hysterectomy, medical management with the oral contraceptive pill (OCP) and tranexamic acid was instituted, with good effect. Months later, after a long road trip, she presented with left leg swelling, and a Doppler ultrasound confirmed an extensive deep vein thrombosis (DVT). She was commenced on warfarin for anticoagulation but presented again with menorrhagia precipitated by overanticoagulation. After initial stabilization with multiple blood transfusions and reversal of anticoagulation, the warfarin was ceased in favour of enoxaparin and she underwent inferior vena cava (IVC) filter insertion prior to a total abdominal hysterectomy. Mass effect from large uterine fibroids can cause venous thromboembolism (VTE). A duplex ultrasound of the lower limbs if a woman presents with a large fibroid could identify asymptomatic DVTs in such women. A prehysterectomy IVC filter would then reduce their risk of postoperative pulmonary embolism. Medical management of menorrhagia with procoagulants should be avoided for management of menorrhagia in such women given their higher risk of developing VTE.

Urological complications of uterine leiomyoma: a review of literature

INTRODUCTION

Uterine leiomyomas are common gynecologic tumor in reproductive-aged women, by age 50, diagnosis shared by urologist, gynecologists and radiologists.

OBJECTIVE

The goal of this article is to review the current literature, study the impact of leiomyoma on female lower urinary tract, examine the cause female sexual dysfunction and provide a comprehensive review of current diagnostic, imaging studies, and current treatment of leiomyoma.

METHODS

Clinical leiomyoma studies published from 1956 through 2015 were identified using the PubMed search engines and the key words leiomyoma, fibroid in the current literature. Impact of leiomyoma on the lower urinary tract including female sexual dysfunction was reviewed with terms of "urinary retention", "bladder", "urethra", "dyspareunia", "incontinence", "incomplete bladder emptying", "female sexual dysfunction", and "lower urinary tract" to study the urological and sexual effects of leiomyoma. Literature related to leiomyoma was reviewed from 1965 to present.

RESULTS

Women with uterine leiomyomata complained of pelvic pain, menstrual irregularities, infertility, lower urinary tract symptoms and sexual dysfunction.

CONCLUSION

Leiomyoma is a common tumor of the uterus that often clinically impacts on the lower urinary tract and results in urological and sexual symptoms. Leiomyoma can compress and grow into and become adherent to the bladder and surrounding pelvic organs or metastasize into peritoneal organs. Leiomyoma can enlarge and compress the urinary bladder, urethra, and lower end of the ureters. Leiomyoma can cause embarrassing sexual dysfunction in females. Current literature of non-surgical and surgical therapy of leiomyoma is described.

Unusual Presentation of Recurrent Pyogenic Bilateral Psoas Abscess Causing Bilateral Pulmonary Embolism by Iliac Vein Compression

Patient: Male, 47

Final Diagnosis: Bilateral psoas abscess • acute lower extremity deep vein thrombosis • bilateral pulmonary embolism

Symptoms: Progressive left leg swelling • productive cough with whitish sputum • right flank pain

Medication: Antibiotics and anticoagulation

Clinical Procedure: CT-guided percutaneous drain placement

Specialty: Internal Medicine/Critical Care

Sudden Death by Pulmonary Thromboembolism due to a Large Uterine Leiomyoma with a Parasitic Vein to the Mesentery

The pathophysiology of venous thrombosis is classically attributed to alterations in one or more components of Virchow's triad: hypercoagulability, stasis, and damage to the vascular endothelium. Deep vein thrombosis (DVT) may lead to pulmonary thromboembolism (PE), and the latter is culpable for many deaths annually in the United States; however, DVT as a complication of uterine leiomyoma has rarely been reported. We report a case of a 57-year-old woman whose death was due to a large pedunculated subserosal leiomyoma externally compressing the pelvic veins resulting in stasis and venous thrombosis leading to fatal PE. The association of large pelvic masses with venous thrombosis has clinical implications, since prophylactic surgery could be life-saving.

Venous thromboembolism secondary to uterine fibroids: a case of phlegmasia cerulea dolens and review of the literature

Uterine fibroids are usually benign soft tissue tumors, however, when they become large, they can cause external venous compression. We present a case of a 45-year-old woman who presented with phlegmasia cerulea dolens from a large uterine fibroid. She was successfully treated with hysterectomy, venous thrombectomy, and fasciotomy. We review the literature for previous reports of venous thromboembolism resulting from uterine fibroids. The patient characteristics, thrombotic complications, and treatment modalities are reviewed.