Saddle Pulmonary Embolus and Simultaneous Common Carotid and Subclavian Artery Emboli.

A patent foramen ovale (PFO) is present in 27-35% of the population. Right to left cardiac shunts predispose patients to arterial emboli in the presence of venous thromboembolisms. Paradoxical embolus should be suspected in patients with deep venous thrombosis (DVT) and arterial emboli. A 45-year-old man with hypercoagulability and history of DVT presented with a week-long history of chest pain, shortness of breath, and left arm numbness. Imaging showed a saddle pulmonary embolus (PE) and emboli involving the aortic arch, left common carotid, and left subclavian artery. The patient proceeded with an endovascular thrombectomy of the pulmonary artery, followed by open thrombectomy. Echocardiogram confirmed a right to left intra-cardiac shunt consistent with a PFO. Paradoxical emboli are rare manifestations of venous thromboemboli in patients with right to left intra-cardiac shunts. Patients should be evaluated for these to help prevent further manifestations.

Inferior Vena Cava Filter Occlusion Causing Phlegmasia Alba Dolens.

Phlegmasia alba dolens is a rare sequela of acute extensive venothrombus of the iliofemoral segments. Rarely, phlegmasia alba dolens can also result from clotted inferior vena cava filter. A 39-year-old with protein S deficiency, and prior inferior vena cava filter placement after remote trauma presented to the emergency department with progressive bilateral lower extremity pain and swelling. Venous duplex revealed extensive bilateral deep vein thromboses from the external iliac veins to popliteal veins, as well as thrombophlebitis of the left great saphenous vein. Venography confirmed patency of the suprarenal vena cava with abrupt occlusion of the infrarenal segment at the level of the inferior vena cava filter. The filter was removed followed by endovascular thrombectomy and adjunctive venoplasty. The patient progressed well and discharged on therapeutic anticoagulation. This case illustrates that a staged endovascular approach may be utilized for acute on chronic caval thrombosis and filter removal.

Burkitt Lymphoma Presenting as Perforated Appendicitis.

Appendicitis is the most common indication for an emergent abdominal operation in the pediatric population. Fewer than .015% of patients who undergo appendectomy for presumed appendicitis are diagnosed with primary lymphoma after evaluation of pathology specimen. 1 Of these primary lymphomas, 29.5% are Burkitt lymphoma. Burkitt lymphoma is an aggressive B-cell lymphoma characterized by translocation and dysregulation of the c-Myc gene. Intraabdominal extranodal Burkitt lymphoma has a polymorphic presentation that includes bowel obstruction, intussusception, and appendicitis. Here we report a case of an adolescent patient who was initially admitted for medical management of perforated appendicitis but was diagnosed with Burkitt lymphoma during his hospital course.