title: Recurrent pulmonary embolus despite adequate anticoagulation: the case for routine cancer screening, prompted by an uncommon cause.
abstract: A middle-aged patient presented with dyspnoea, haemoptysis and weight loss following a recent admission for pulmonary embolus, diagnosed on CT pulmonary angiogram (CTPA). The patient was anticoagulated with warfarin to a therapeutic range 2-3. There was no relevant medical history. On examination, the pulse was 105 bpm and blood pressure was 70/50 mm Hg. Oxygen saturation was 94% on air. Repeat CTPA revealed extension of the clot burden, now a saddle embolus occluding pulmonary outflow. The patient underwent emergency surgical embolectomy, and histology of the excised clot revealed the underlying cause--a malignant, high-grade sarcoma of the pulmonary vasculature. The target international normalised ratio was increased to 3-4. Postoperatively, the patient developed a large malignant pericardial effusion which required urgent percutaneous drainage. The patient eventually underwent targeted chemotherapy, which extended patient survival. The patient passed away a year later from progressive right-sided heart failure as a result of cor pulmonale.
authors.affiliation: Department of Anaesthetics and Critical Care, Northampton General Hospital, Northampton, UK.
authors.forename: Daniel
authors.identifier: http://orcid.org/0000-0003-3315-9491
authors.initials: D
authors.lastname: Bendel
authors.affiliation: Department of Cardiovascular Medicine, The Whittington Hospital, London, UK.
authors.forename: Chee Yee
authors.initials: CY
authors.lastname: Loong
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D055088:Early Detection of Cancer; D006801:Humans; D008175:Lung Neoplasms / Q000150:complications*; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000209:etiology* / Q000517:prevention & control; D012008:Recurrence; D012509:Sarcoma / Q000150:complications*; D019043:Vascular Neoplasms / Q000150:complications*; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin