Clinical Case 24—Multisite thrombosis in a patient with acute coronary syndrome: when the unlikely becomes reality

We present the case of a 78-year-old patient, admitted for chest pain for 1 week prior to presentation. In the view of the electrocardiographic changes, myocardial cytolysis and severely decreased left ventricular ejection fraction, an acute coronary syndrome was highly likely. Coronary angiography identified a 99% stenosis in the anterior descending artery for which an angioplasty was performed.

Afterwards, the patient becomes dyspneic, hemodynamically unstable, suggesting a pulmonary embolism. The pulmonary CT angiography confirmed the presence of a thrombus in the right pulmonary artery. During thrombolysis, the patient was hemodynamically stable, without complications, achieving improvement of symptoms.

The next day, the patient had pain at the inguinal level and a significant decrease in hemoglobin. A soft tissue ultrasound was performed, showing a partially thrombosed femoral pseudoaneurysm. Vascular Doppler ultrasound revealed multiple occlusive thrombi in the femoral, popliteal and posterior tibial veins. Echocardiography confirms the presence of floating thrombi in the right ventricle.

After a first dose of Apixaban the patient develops erythema. Allergology tests showed intolerance to Apixaban. Considering the associated pro-coagulant status, we performed a series of biological and imaging explorations that showed the presence of a malignant brain neoplasm that induced the complications mentioned above. Unfortunately, the patient died one month after discharge.

The occurrence of pulmonary embolism secondary to revascularized acute myocardial infarction, apparently without risk factors, requires identification of underlying pathologies associated with a pro-coagulant status. Unfortunately, often, behind such events, we discuss about an oncological pathology. Figure 1

3D reconstruction of right pulmonary artery thrombosis.