Case Report

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Case Report
Presented by PGY1 ???
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Patient Profile

• Chart Number51748574
• Name?O
• Gender/Age female/ 82
• Occupation Nil
• Marital status Married
• Ethnic origin ??
• Place of Residence ???
• Source of information patient
• Date of admission 2009/02/28
• PHxHCVD, DM.

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Chief complaint

• General malaise in recent one month.

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Present illness

• Past history of HCVD, Type 2 DM under control at
  LMD.
• Hardly get up from bed and complained of DOE.
• General malaise in recent one month, a/w
  dizziness, chest tightness, DOE, poor appetite,
  BW loss( ? kg).(had visited LMD without
  improvement.)
• no fever or chills, no cough, no chest pain, no
  abd pain, no diarrhea or constipation, no tarry
  or blood stool.

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Past History

• HCVD under control for more than 5 yrs.
• DM for 2-3 years.

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Personal and Family History

• Denied hx of smoking or alcoholic drinking.
• No F.H. of cancer.

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Review of Systemic

• 1.General     Fatigue(),weakness(),fever(-),ch
  ills(-),body weight loss(),insomnia(). 2.Skin,
  hair, nails      Pigmentation(-),jaundice(-),cya
  nosis(-),pruritis(-),rash(-), hair loss(-),easy
  bruising(-). 3.Heent      HeadHeadache(-),dizz
  iness(),vertigo(-),syncope(-),trauma(-).     
  EyesBlurred vision(-),color vision(-),photophobia
  (-),pain(-), diplopia(-).     
  EarsPain(-),discharge(-),hearing
  impairment(-),tinnitus(-).     
  NoseEpistaxis(-),discharge(-),nasal
  obstruction(-), smell sensory loss(-).     
  Throat, oral cavitySore throat(-),hoarseness(-),g
  um bleeding(-), oral ulcer(-). 4.Neck     
  Neck pain(-),neck mass(-). 5.Respiratory system
       Cough(-),sputum(-),wheezing(-),tachypnea(),
  accessory muscle use(-), hemoptysis(-)
  6.Cardiovascular systems      Hypertension (),
  arrhythmia (-), dyspnea on exertion (), dyspnea
  at rest (-), orthopnea (-), paroxymal dyspnea on
  night (-), chest pain(-), palpitation (-),
  claudication (-). 7.GI system      Dysphagia
  (-), nausea (-), vomiting (-), hematemesis (-),
  abdominal pain (-), constipation (-), diarrhea
  (-), melena (-), bowel habit change (-)
• 8.GU system      Dysuria (-), urinary frequency
  (-), polyuria (-), hematuria (-), Decresed urine
  output.(-)9. Hematopoietic systems      Anemia
  (-), dizziness (-), patechiae (-), ecchymosis
  (-), lymphadenopathy (-), hepatomegaly (-),
  splenomegaly (-), bone pain (-).
  10.Neuro-psychiatry systems      Headache (-),
  vertigo (-), syncope (-), seizure (-), dysphagia
  (-), dysarthria (-), diplopia (-), ataxia (-),
  tremor (-), rigidity (-), paralysis
  (-),paresthesia (-), anxiety (-), depression (-),
  irritability (-). 11.Musculoskeletal system
       Muscle wasting (-), swelling (-), local
  heat (-), clubbing fingers (-), joint deformity
  (-), contracture (-), arthralgia (-), bone pain
  (-), limitation of motion (-), rigidity (-),
  fracture (-).

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Physical examination

• Vital signsBT36.9 ?C , PR71 bpm, RR20/min,
  BP149/91 mmHg.
• General appearance chronic ill, well development
  nourished
• Consciousness E4V5M6, alerted.
• Skin turgor--- normal, no paper skin
• HEENT no anemic conjunctiva, no icteric sclera
• Neck no palpable lymphadenopathy.
• Chest Regular heart beats, coarse breathing
  sounds,
• Mild decreased breathing sound
  over LLL.
• Abdomen soft without tenderness, normoactive
  bowel sounds.
• Extremities No pitting edema.
• Neurologic exam. No focal neurologic deficit.

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Tentative diagnosis

• General malaise, cause?
• -- Electrolyte/anemia?
• -- Infection? (UTI, pneumonia)
• -- Cardiogenic?

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Initial survey at ED

• CBC/DC, BCS
• CxR, ECG
• U/A.

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(No Transcript)
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U/A Unremarkable findings.
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Disposition

• Admission to Chest ward.

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At ward

• Thoracentesis was arranged on 3/2

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• Gram stain not found.
• Cytology (2 sets)
• -- Malignant, most likely adenocarcinoma.
• CEA101

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• Chest CT

--Irregular shaped soft tissue mass lesion with
heterogeneous enhancement pattern over LUL, with
the largest diameter 3.2 cm. -- Paratracheal,
supracarina, Lt pericaridal lymphoadenopathy
sized 2.9cm. -- Lt adrenal gland tumor,
metastasis could not be completely R/O. -- Bil
pul a partial embolism could not be completely
R/O. If clinical indicated, suggest V/Q scan
correlation.
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Hospital course

• Lung Perfusion Study
• -- ventilation study not done
• Bone scan no bony metastasis
• Family refused chemotherapy and support care was
  given.
• Left lower leg swelling? Doppler (not done)

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Final diagnosis

• Adenocarcinoma of lung cancer, left upper lung,
  with malignant pleural effsuion, T4N3M0,
  stageIIIB
• Suspected pulmonary embolism
• Suspect deep vein thrombosis, left leg
• Hypertensive cardiovascular disease
• Type 2 diabetes mellitus

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Discussion

• Hypercoagulable disorders
• associated with malignancy

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Presentation of Thrombotic episodes

• Migratory superficial thrombophlebitis
  (Trousseau's syndrome)
• Idiopathic deep venous thrombosis and other
  venous thrombosis
• Nonbacterial thrombotic endocarditis (marantic
  endocarditis)
• Disseminated intravascular coagulation (DIC)
• Thrombotic microangiopathy (eg, hemolytic-uremic
  syndrome)
• Arterial thrombosis

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Factors contributing to venous thrombosis

• hypercoagulability
• external compression of vessels
• vascular invasion

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Pathogenesis of the hypercoagulable state
associated with malignancy

• Host tissues
• -- P-selectin ? ? the expression of tissue
  factor on monocytes and endothelial cells.
• -- Monocytes induced to produce tissue factor
  and other direct factor X activators
• --   ? platelet reactivity
• -- Endothelial cells  TNF and IL-1 ? the
  expression of leukocyte adhesion molecules,
  platelet activating factor, and tissue factor.
• Comorbid factors bed rest, infection, surgery,
  CVC,and drugs.

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Intact tumor cells
Cancer procoagulant (CP)
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TROUSSEAU'S SYNDROME 

• 1865 by Trousseau.
• unexplained DVT, followed a year later by the
  development of gastric carcinoma
• a recurrent and migratory pattern and involvement
  of superficial veins, frequently in unusual sites
  such as the arm or chest.

Armand Trousseau (18011867)
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Associated cancers

• Pancreas 24 percent
• Lung 20 percent
• Prostate 13 percent
• Stomach 12 percent
• Acute leukemia 9 percent
• Colon 5 percent

Sack, GH Jr, Levin, J, Bell, WR. Trousseau's
syndrome and other manifestations of chronic
disseminated coagulopathy in patients with
neoplasms Clinical, pathophysiologic, and
therapeutic features. Medicine (Baltimore) 1977
561.
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VENOUS THROMBOEMBOLISM

• Associated malignancy
• -- Hematologic malignancies (adjusted OR 28)
• -- Lung (OR 22)
• -- Gastrointestinal tract (OR 20),
• -- Brain (OR 6.7),
• -- Kidney (OR 6.2)
• -- Breast (OR 4.9).

Blom, JW, Doggen, CJ, Osanto, S, Rosendaal, FR.
Malignancies, prothrombotic mutations, and the
risk of venous thrombosis. JAMA 2005 293715.
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• The greatest absolute number of episodes of
  DVT/PE --
• ?lung, ?colon, and ? prostate,
• The highest rates of DVT/PE (number of episodes
  per 10,000 patients with a specific malignancy)
• ?ovary, ?brain, ?pancreas, and ?lymphoma.

Levitan, N, Dowlati, A, Remick, SC, et al. Rates
of initial and recurrent thromboembolic disease
among patients with malignancy versus those
without malignancy. Risk analysis using Medicare
claims data. Medicine (Baltimore) 1999 78285.
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Treatment

• Use of long-term LMW heparin is more effective
  than warfarin in reducing the incidence of
  recurrent VTE in cancer patients without
  significantly increasing the risk of bleeding.
• -- Dalteparin (Fragmin) 200 IU/kg once/day SQ
  for the first month ? 150 IU/kg SQ once/day for
  the subsequent 5 months (lt 18,000 IU/day)

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RECOMMENDATIONS 

• INITIAL treatment with LMW heparin over the use
  of oral anticoagulants (Grade 2A).
• Relative contraindication
• ? active bleeding ?recent surgery,
  ?preexisting bleeding diathesis, ?platelet count
  lt50,000/microL, ?x coagulopathy)

2007 guidelines from the American Society of
Clinical Oncology (ASCO), the 2007 clinical
practice guidelines of the American College of
Physicians and the American Academy of Family
Physicians, the 2008 NCCN Guidelines, and the
2008 ACCP Guidelines
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The End

• Thanks for your attention