Pulmonary vein thrombosis in a patient with polycythemia vera

Pulmonary vein thrombosis associated with metastatic uterine leiomyosarcoma: a case report

BACKGROUND

Pulmonary vein thrombosis (PVT) is rarely associated with malignancies. Leiomyosarcoma, a malignant tumor originating from smooth muscles, has never been reported as the etiology of PVT.

CASE PRESENTATION

In this case report, we described a 43-year-old Kurdish woman with a known case of leiomyosarcoma who presented with hemoptysis, dyspnea, and pleuritic chest pain. Chest computed tomography (CT) angiography revealed a thrombus in the left infero-posterior pulmonary vein. She was successfully treated with unfractionated heparin administered intravenously followed by orally administered warfarin. At the end of the article, we describe and compare other reports of malignancy-related PVT.

CONCLUSIONS

While malignancies are not a common cause of PVT, both primary lung tumors and metastatic cancers could be associated with PVT. Delay in diagnosis may lead to serious complications and even death. Therefore, clinicians should be aware of the possibility of the development of PVT in different malignancies for appropriate diagnosis and treatment.

[Pulmonary Hypertension and Polycythemia vera]

INTRODUCTION

 Chronic myeloproliferative diseases are rare causes of PH class 5 according to Nice classification 2018. The present case reports show different courses, on the one hand with a primary manifestation of a PH and subsequently a PV, on the other hand with the development of a PH in the context of a PV.

CASE REPORTS

 1) At first contact, a 75-year-old female patient who complained progressive dyspnea and had evidence of stress-PH in the right heart catheter. During the course she developed a resting PH of up to 70 mmHg systolic despite initial monotherapy and subsequent dual therapy for PH. After 5 years she had the diagnosis of polycythemia vera, treated with hydroxycarbamide and subsequent phlebotomies. In the further course increasing cardiac decompensation and death. 2) 74-year-old female patient at the time of diagnosis of chronic megakaryocytic-granulocytic myelosis. After 7 years, evidence of polycythemia vera (V617F mutation in the JAK2 gene), a monoclonal gammopathy. In the case of splenomegaly, irradiation of the spleen was carried out and, after 1 year, therapy with ruxolitinib was started. After another 2 years, with increasing dyspnea, pulmonary hypertension (CTEPH) with a PA-mean of 43 mmHg and a PVR of 4.5 WE were detected. With anticoagulation and riociguat therapy exercise capacity and PA pressures were only temporarily improved. Within 1 year restrictive ventilation, hypoxemia, heart failure (EF 45 %) with leading right heart decompensation and cardiorenal syndrome developed. Dialysis showed only short-term recompensation, and the patient died.

DISCUSSION

 The case reports are characterized by a combination of PV and PH, with different temporal sequence, as well as only a low influence of PH-specific therapy, with subsequent progressive cardiac decompensation. Thus, they reflect the different etiologies, clinical manifestations, and the low therapeutic influence of PH in myeloproliferative disorders. The value of PH-specific therapy remains unclear, especially in view of different pathomechanisms in the genesis of PH.

CONCLUSION

 Patients with myeloproliferative diseases require screening for PH. In the course of PH, myeloproliferative disease can unmask or develop. The therapeutic influence on PH is limited.

Diffuse arterial embolization secondary to pulmonary vein thrombosis

Pulmonary vein thromboses (PVT) is a complication of lung malignancy and can be complicated by arterial embolic phenomenon. Patient is a 69-year-old female with a history of coronary artery disease and recent pneumonia seen on chest x-ray who presented with progressive headache, left arm numbness and abdominal pain. She was found to have numerous bilateral strokes, bilateral renal infarction and splenic infarction. CT Chest showed a right upper lobe mass compressing the pulmonary veins with filling defects concerning for thrombus. Diagnosis of PVT is made with CT angiogram, echocardiogram and MRI. Treatment consists of anticoagulation and treatment of underlying factors.

Pulmonary Vein Tumor Thrombus With Intracardiac Extension Secondary to Poorly Differentiated Bronchogenic Carcinoma

Pulmonary vein thrombosis (PVT) is a rarely encountered disease entity with varied clinical presentations. It has been reported to be associated with underlying lung malignancy in multiple case reports. Diagnosis can be challenging due to nonspecific symptoms on presentation. Herein, we report a 67-year-old male patient with a history of extensive smoking and chronic obstructive pulmonary disease (COPD) who presented with multiple hemoptysis episodes. CT scan of the chest with contrast showed multiple right lower lobe (RLL) lung masses and a thrombus in the inferior pulmonary vein. After various imaging modalities and transthoracic biopsy of the lung mass, the patient was diagnosed with pulmonary vein tumor thrombus secondary to poorly differentiated bronchogenic carcinoma with intracardiac extension. The patient was started on Eliquis for anticoagulation and is currently in the process of beginning chemo/radiation therapy for the underlying malignancy.

Pulmonary vein thrombosis in patients with medical risk factors

Pulmonary vein thrombosis in patients with medical illnesses has been rarely reported, and it is also rarely reported in those with no risk factors. We report 2 patients with pulmonary vein thrombosis, 1 with metastatic renal cell carcinoma and 1 with presumed pulmonary aspergillosis. Thrombi or tumors in a pulmonary vein are clinically important because they may cause systemic embolism or hemoptysis.