A case of pulmonary tumor embolism syndrome with thrombus in transit.

The incidence of pulmonary tumor embolism in patients with solid tumors is estimated to be between 3% and 26% yet is rarely diagnosed. In this case, a 74-year-old male with sarcomatoid variant of urothelial carcinoma and recently diagnosed left renal vein thrombus treated with low-molecular-weight-heparin, presented to the emergency department with acute syncope and dyspnea. He was found to have CT imaging of segmental and subsegmental arterial filling defects, a right atrial filling defect concerning for thrombus in transit and was diagnosed with pulmonary tumor embolism syndrome. The patient was treated with aspiration thrombectomy, with pathology demonstrating sarcomatoid urothelial carcinoma cells. He was initiated on a combination of gemcitabine plus carboplatin to decrease the tumor burden. While pulmonary tumor embolism syndrome is associated with a poor prognosis, prompt diagnosis and initiation of cancer-specific therapies can significantly improve survival.

A 65-Year-Old Man With Weight Loss, Peripheral Neuropathy, and Lower Extremity Swelling.

CASE PRESENTATION: A 65-year-old man with no past medical history sought treatment at the hospital with lower extremity swelling, pain, tingling in a stocking-glove distribution, and syncope. He reported a 23-pound unintentional weight loss. He felt unsteady walking with a couple of falls, and his exercise tolerance was limited to several hundred feet. He did not report vision changes, dysphagia, bowel or bladder problems, tremor, orthopnea, lightheadedness, or chest pain. He did not report any history of substance misuse, high-risk sexual behavior, or concerning exposures. The patient was admitted for further workup.

Residence at moderately high altitude and its relationship with WHO Group 1 pulmonary arterial hypertension symptom severity and clinical characteristics: the Pulmonary Hypertension Association Registry.

BACKGROUND: WHO Group 1 pulmonary arterial hypertension is a progressive and potentially fatal disease. Individuals living at higher altitude are exposed to lower barometric pressure and hypobaric hypoxemia. This may result in pulmonary vasoconstriction and contribute to disease progression. We sought to examine the relationship between living at moderately high altitude and pulmonary arterial hypertension characteristics. METHODS: Forty-two US centers participating in the Pulmonary Hypertension Association Registry enrolled patients who met the definition of WHO Group 1 pulmonary arterial hypertension. We utilized baseline data and patient questionnaire responses. Patients were divided into two groups: moderately high altitude residence (home ≥4000 ft) and low altitude residence (home <4000 ft) based on zip-code. Clinical characteristics, hemodynamic data, patient demographics, and patient reported quality of life metrics were compared. RESULTS: Controlling for potential confounders (age, sex at birth, body mass index, supplemental oxygen use, race, 100-day cigarette use, alcohol use, and pulmonary arterial hypertension medication use), subjects residing at moderately high altitude had a 6-min walk distance 32 m greater than those at low altitude, despite having a pulmonary vascular resistance that was 2.2 Wood units higher. Additionally, those residing at moderately high altitude had 3.7 times greater odds of using supplemental oxygen. CONCLUSION: Patients with pulmonary arterial hypertension who live at moderately high altitude have a higher pulmonary vascular resistance and are more likely to need supplemental oxygen. Despite these findings, moderately high altitude Pulmonary Hypertension Association Registry patients have better functional tolerance as measured by 6-min walk distance. It is possible that a "high-altitude phenotype" of pulmonary arterial hypertension may exist. These findings warrant further study.

A 44-Year-Old Woman With Chest Pain and Dyspnea.

CASE PRESENTATION: A 44-year-old woman with a medical history of anti-phospholipid antibody syndrome complicated by recurrent pulmonary emboli with subsequent chronic hypoxic respiratory failure (3 L/min oxygen baseline) presented to the ED with 2 to 3 weeks of shortness of breath and pleuritic chest pain that radiated to the center of her back. These symptoms were accompanied by an increase in her oxygen requirement from 3 L/min to 6 L/min. She also reported nausea, vomiting, lightheadedness, and dizziness for the same period. The patient had two prior pulmonary emboli in the same year, which prompted a hypercoagulable workup, ultimately revealing a diagnosis of antiphospholipid antibody syndrome. The second pulmonary embolus occurred while the patient was on coumadin, though achieving a therapeutic international normalized ratio was challenging. At the recommendation of the Hematology Department, she was transitioned to systemic anticoagulation with low-molecular-weight heparin (LMWH) at a dose of 1.5 mg/kg twice daily, which was her regimen at the time of admission. The patient confirmed total compliance with her anticoagulation therapy, and she denied any recent travel or long periods of being sedentary. She was up to date on her age-appropriate cancer screening, without any evidence of active malignancy.

A 49-Year-Old Woman With Chest Pain, Cough, and Hypoxemia After a Seizure.

CASE PRESENTATION: A 49-year-old woman with a medical history of epilepsy presented to the ED 1 h after a single, 15-min, witnessed, tonic-clonic seizure. Over the preceding 6 months, she had experienced five similar seizures of shorter duration. There were no recent changes to her phenytoin dose nor had she started any new medications. The patient had traveled to Jamaica 3 weeks before presentation, where she smoked marijuana once but otherwise had not used illicit substances nor had she used tobacco or alcohol. She states she felt well during and after the trip until this presentation. While being evaluated by the neurology service, the patient complained of sudden-onset chest pain and cough with associated hypoxemia. She denied changes in her sleep habits, she had not experienced any fevers, and she had no changes in her exercise tolerance. The patient was admitted to the general medicine floor for further workup.