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A4004 - A Rare Fatal Case of ""Thrombotic Storm"" Caused by Poorly Differentiated Lung Adenocarcinoma
Author Block: S. McGowan1, K. Warrior2, B. T. Tran2; 1Internal Medicine, Rush University Medical Center, Chicago, IL, United States, 2Rush University Medical Center, Chicago, IL, United States.
Introduction “Thrombotic storm” describes a rapidly accelerated course of hypercoagulability that develops in multiple organ systems over days to weeks. We describe a rare case of thrombotic storm due to primary lung adenocarcinoma.
Clinical Case A 38-year-old male with history of hypothyroidism presented with bilateral leg pain following a recent trip. He was found to have thrombi in the bilateral tibial peroneal and calf veins, as well as pulmonary emboli (PE) with infarcts in the left middle and lower lobes. He was placed on apixiban but subsequently was found to have propagation of his popliteal thrombus, requiring catheter-guided thrombolysis. Despite systemic anticoagulation, he developed recurrent deep vein thromboses (DVTs), PEs with pulmonary infarcts, a triscupid valve thrombus, and venous testicular infarction, and underwent iliac vein stenting, inferior vena cava filter placement, and multiple catheter-directed Tissue Plasminogen Activator infusions. His anticoagulation regimen was serially broadened to include argatroban and dabigatran, in addition to apixiban. Coagulopathy workup was only notable for factor V Leiden heterozygosity. A pan-computerized tomography (CT) did not reveal any masses or evidence of malignancy. His course was complicated by recurrent epistaxis, hemoptysis, and hypoxia, which were thought due to diffuse alveolar hemorrhage; however, given his clot burden, anticoagulation was unable to be stopped completely. His condition continued to deteriorate, and he expired following a pulseless electrical activity arrest due to hypoxic respiratory failure and blood loss anemia. On autopsy, he was found to have occult, poorly differentiated left lower lung adenocarcinoma.
Discussion Thrombotic storm is a rare condition, only described with a handful of case reports. Common characteristics include: young age, recurrent arterial or venous thromboemboli occurring within days to weeks, progressive, unexplained recurrence or poor therapeutic response, and severe exacerbations with interrupted treatment. Common triggers include pregnancy, inflammation, trauma, surgery, and infection, but active malignancy has not previously been described as a cause. Thrombotic storm shares overlap with Catastrophic Antiphospholipid Syndrome, which may involve a cytokine storm and pro-coagulant gene expression that can be activated in malignancy. In our patient, antiphospholipid antibodies were absent and extensive work up for malignancy was negative, including multiple CTs of his chest that failed to demonstrate lung mass. While hypercoagulability is common in malignancy, the rapidly progressive course and resistance to treatment in our patient describes a rare case of thrombotic storm in malignancy. Despite the negative workup in our patient, malignancy should be considered in cases of thrombotic storm.