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Systemic Emboli Associated With Lung Cancer
IMAGES IN THE MEDICAL SCIENCES
Systemic Emboli Associated With Lung Cancer Hermann T. Simo, MD, Aahd Kubbara, MD, Neha Varshney, MD, Madiha Fida, MD, Ragheb Assaly, MD* and Vasuki Anandan, MD *Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (E-mail: [email protected]). The authors have no financial or other conflicts of interest to disclose.
FIGURE.
CASE PRESENTATION
A
49-year-old man presented with decreased strength and sensation on the left side, inability to move his left side of the body and with slurring of speech of a few days' duration. His smoking history was significant for 60 pack years. Family history was noncontributory. On physical examination, it was revealed that he was unable to look to his left side, had bluish discoloration of the left foot (Figure A) and had absence of left dorsalis pedis pulse. Blood cultures showed negative result. Chest X-ray showed a mass on the left lower lung suspicious of malignancy. The echocardiogram revealed a mass measuring 1.6 0.9 cm2 in the left atrium near opening of pulmonary vein. A duplex scan of the lower extremities showed the left proximal femoral artery completely occluded. A magnetic resonance imaging scan of the brain showed right middle cerebral artery infarct and ischemic signs on the left and right posterior cerebral artery distribution suggestive of a central embolic source. An autopsy was conducted after he passed away.
The autopsy report revealed a centrally located primary adenocarcinoma involving the left upper lobe of the lungs (Figure B, red circle) with metastasis to peripancreatic and para-aortic lymph nodes, small intestinal wall and both adrenals. In addition, multiple peripheral organizing emboli were noted in the adrenals, spleen, lung and liver (Figure C, blue circle). The liver also showed centrilobular necrosis secondary to right heart dysfunction likely secondary to pulmonary emboli. The brain showed an acute right middle cerebral artery infarction with edema. Examination of the left atrium revealed a large antemortem thrombus that was previously thought to be a heart mass on echocardiography. Most of the emboli in the blood vessels had no tumor cells, all of these findings are most likely a result of coagulopathy secondary to malignancy as the cause for emboli.1
REFERENCE 1. Nichols L, Saunders R, Knollmann FD. Causes of death of patients with lung cancer. Arch Pathol Lab Med 2012;136(12):1552–7.
Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved. www.amjmedsci.com www.ssciweb.org
637
Systemic Emboli Associated With Lung Cancer Hermann T. Simo, MD, Aahd Kubbara, MD, Neha Varshney, MD, Madiha Fida, MD, Ragheb Assaly, MD* and Vasuki Anandan, MD *Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (E-mail: [email protected]). The authors have no financial or other conflicts of interest to disclose.
FIGURE.
CASE PRESENTATION
A
49-year-old man presented with decreased strength and sensation on the left side, inability to move his left side of the body and with slurring of speech of a few days' duration. His smoking history was significant for 60 pack years. Family history was noncontributory. On physical examination, it was revealed that he was unable to look to his left side, had bluish discoloration of the left foot (Figure A) and had absence of left dorsalis pedis pulse. Blood cultures showed negative result. Chest X-ray showed a mass on the left lower lung suspicious of malignancy. The echocardiogram revealed a mass measuring 1.6 0.9 cm2 in the left atrium near opening of pulmonary vein. A duplex scan of the lower extremities showed the left proximal femoral artery completely occluded. A magnetic resonance imaging scan of the brain showed right middle cerebral artery infarct and ischemic signs on the left and right posterior cerebral artery distribution suggestive of a central embolic source. An autopsy was conducted after he passed away.
The autopsy report revealed a centrally located primary adenocarcinoma involving the left upper lobe of the lungs (Figure B, red circle) with metastasis to peripancreatic and para-aortic lymph nodes, small intestinal wall and both adrenals. In addition, multiple peripheral organizing emboli were noted in the adrenals, spleen, lung and liver (Figure C, blue circle). The liver also showed centrilobular necrosis secondary to right heart dysfunction likely secondary to pulmonary emboli. The brain showed an acute right middle cerebral artery infarction with edema. Examination of the left atrium revealed a large antemortem thrombus that was previously thought to be a heart mass on echocardiography. Most of the emboli in the blood vessels had no tumor cells, all of these findings are most likely a result of coagulopathy secondary to malignancy as the cause for emboli.1
REFERENCE 1. Nichols L, Saunders R, Knollmann FD. Causes of death of patients with lung cancer. Arch Pathol Lab Med 2012;136(12):1552–7.
Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved. www.amjmedsci.com www.ssciweb.org
637