Diagnosis and Treatment of Massive Pulmonary Thromboembolism in a Patient with Metastatic Colon Adenocarcinoma

Abstract

Aim: Massive pulmonary thromboembolism (PTE) is one of the cause of unexpected deaths in hospitalized patients. Our aim is to present diagnosis and treatment of massive pulmonary thromboembolism in a patient with pneumonia and cancer. Case: A 52 years old male with a metastatic colon adenocarcinoma, admitted to the emergency department with shortness of breath, one month after the right hemicolectomy and chemotherapy. The physical examination of the patient: general condition was bad and he had tachypnea, tachycardia, and rals in the left lung bases and leukocyte: 21.000 K/ml, CRP: 28mg/dl, Ph:7.46, PaO2:56.6, PaCO2:23.2, SO2:%82, HCO3:19.8. Tachypnea, tachycardia, hypoxia, hypocapnia, and respiratory alkalosis was observed, PTE was considered and diagnosed by CT pulmonary angiography. 50 mg Alteplase was applied to the patient. After administration of alteplase, general condition was improved (pH:7.37, PaO2:85.1, PaCO2: 38.9,SO2:98.5%, HCO3:20.3). Conclusion:Pneumonia, may mask the diagnosis of PTE and should be considered in patients with dyspnea, hypocapnia, hypoxia, and hypotension

Keywords

• Colonic Neoplasms, Pneumonia, Pulmonary Embolism, Thrombolytic Therapy

References

1. Davidson BL (2000). Risk assessment and prophylaxis of venous thromboembolism in acutely and/or critically ill patients. Haemostasis, 30 (2): 77-81.
2. Goldhaber SZ, Visani L, De Rosa M (1999). Acute pulmonary embolism: Clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet, 353 (9162): 1386-1389.
3. Kasper W, Konstantinides S, Geibel A, Tiede N,Krause T, Just H (1997). Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pul-monary embolism. Heart, 77(4): 346-349.
4. Alpert JS, Smith R, Carlson J, Ockene IS, Dexter L,Dalen JE (1976). Mortality in patients treated for pulmonary embolism. JAMA, 236(13): 1477-1480.
5. Sandler DA, Martin JF (1989). Autopsy proven pulmonary embolism in hospital patients: Are we detecting enough deep vein thrombosis? J R Soc Med, 82(4): 203-205.
6. Neuhaus A, Bentz RR, Weg JG (1978). Pulmonary embolism in respiratory failure. Chest, 73(4): 460-465.
7. Khorana AA, Francis CW, Culakova E, Kuderer NM, LymanGH (2007). Frequency, risk factors and trends for venous thromboembolism among hospitalized cancer patients. Cancer, 110(10): 2339-2346.
8. Blom JW, Doggen CJ, Osanto S, Rosentaal FR (2005). Malignancies, protrombotic mutations, and the risk of venous thrombosis. JAMA, 293(6): 715-722.

9. Geerts W, Pineo G, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al (2004). Prevention of venous thrombo embolism, the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest, 126(3): 338 - 400.
10. Şimşek A, Türkkan Ö, Melek K, Eyüboğlu FÖ (2010). Assessment of Patients with Pulmonary Thromboembolism (PTE) Diagnosed in Our Clinic: 5 Years Experience. Tur Toraks Der, 11: 149-154.
11. Casiato DA (2004). Hematologic complications. In: Casiato DA,Territo MA (eds). Manual of Clinical Oncology. 5th ed.Philadelphia: Lippincott Williams & Wilkins, 651-653.
12. Torbichi A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al (2008). ESC Committee for Practice Guidelines (CPG). Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J, 29(18): 2276 -2315.
13. PIOPED Investigators (1990). Value of the ventilation-perfusion lung scan in acute pulmonary embolism. JAMA, 263(20): 2753-2759.
14. Hasan Yiğit, Elif Ergün (2012). Pulmonary CT Angiography. Turkiye Klinikleri J Radiol-Special Topics, 5(3): 53- 63.
15. Cushman M, Tsai A, Heckbert SR (2001).Incidence rates, case fatality, and recurrence rates of deep vein thrombosis and pulmonary embolus: the Longitudinal Investigation of Thromboembolism Etiology (LITE). Thromb Haemost, 86: 2349.
16. Meyer G, Sors H, Charbonnier B, Kasper W, Bassand JP, Kerr IH et al (1992). Effects of intravenous urokinase versus alteplase on total pulmonary resistance in acutemassive pulmonary embolism: a European multicenter double-blind trial. The European Cooperative Study Group for Pulmonary Embolism. J Am Coll Cardiol, 19(2): 239–245.
17. Goldhaber SZ, Kessler CM, Heit J, Markis J, Sharma GV, Dawley D et al (1988). Randomised controlled trial of recombinant tissue plasminogen activator versus urokinase in the treatment of acute pulmonary embolism. Lancet, 2(8606): 293–298.
18. Meneveau N, Schiele F, Metz D, Valette B, Attali P, Vuillemenot A et al (1998). Comparative efficacy of a two- hour regimen of streptokinase versus alteplase in acute massive pulmonary embolism: immediate clinical and hemodynamic outcome andone-year follow-up. J Am Coll Cardiol, 31(5): 1057–1063.
19. Meneveau N, Schiele F, Vuillemenot A, Valette B, Grollier G, Bernard Y et al (1997). Streptokinase vs alteplase in massive pulmonary embolism. A randomized trial assessing right heart haemodynamics and pulmonary vascular obstruction. Eur Heart J, 18(7): 1141–1148.