Hematology Oncology · Year 2 · from Hematology Oncology

Case 1: Deep Vein Thrombosis and Pulmonary Embolism

Patient Presentation

Demographics: 58-year-old male

Chief Complaint: Left leg swelling and sudden shortness of breath

History of Present Illness: The patient noticed progressive left leg swelling and calf pain over the past 5 days. Today, he developed sudden onset of shortness of breath and mild chest discomfort. He underwent right knee replacement surgery 3 weeks ago and has been relatively immobile since then. He has no prior history of blood clots. He takes lisinopril for hypertension. He denies hemoptysis but reports mild pleuritic chest pain.

Physical Examination:

  • Vital signs: BP 135/85, HR 108, RR 24, Temp 37.2C, SpO2 92% on room air
  • General: Anxious male in mild respiratory distress
  • Lungs: Clear to auscultation, tachypneic
  • Cardiac: Tachycardic, regular rhythm, loud P2
  • Left leg: Significant edema from foot to mid-thigh, warmth, tenderness along femoral vein course
  • Right leg: Post-surgical changes, no acute swelling

Workup and Results

Laboratory:

  • D-dimer: 4,850 ng/mL (markedly elevated; normal <500)
  • Troponin I: 0.15 ng/mL (mildly elevated)
  • BNP: 450 pg/mL (elevated)

Arterial Blood Gas:

  • pH 7.46, pCO2 32 mmHg, pO2 68 mmHg on room air

Imaging:

  • Compression ultrasound left leg: Non-compressible femoral and popliteal veins with echogenic thrombus
  • CT pulmonary angiography: Bilateral pulmonary emboli involving segmental and subsegmental branches; RV/LV ratio 1.2

ECG:

  • Sinus tachycardia, S1Q3T3 pattern, T-wave inversions in V1-V3

Clinical Image

CT pulmonary angiography demonstrating filling defects (arrows) in the pulmonary arteries consistent with acute pulmonary embolism, with evidence of right ventricular strain.

Diagnosis

Proximal Deep Vein Thrombosis with Submassive Pulmonary Embolism

Key features:

  • Provoked VTE (recent surgery with immobilization)
  • Proximal DVT (femoral and popliteal involvement)
  • Submassive PE (RV dysfunction but hemodynamically stable)
  • Elevated biomarkers indicating cardiac strain

Treatment Plan

  1. Immediate anticoagulation:
  • Initiate therapeutic anticoagulation with LMWH or DOAC
  • Consider rivaroxaban 15 mg BID x 21 days, then 20 mg daily
  • Or apixaban 10 mg BID x 7 days, then 5 mg BID
  1. Monitoring:
  • Close hemodynamic monitoring given submassive classification
  • Serial echocardiography to assess RV function
  • Consider ICU admission for first 24-48 hours
  1. Duration of therapy:
  • 3 months minimum (provoked by transient risk factor)
  • Reassess at 3 months; likely can discontinue given clear provocation
  1. Supportive care:
  • Supplemental oxygen
  • Graduated compression stockings for DVT
  1. Not indicated:
  • Systemic thrombolysis (reserved for massive PE with hemodynamic instability)
  • IVC filter (no contraindication to anticoagulation)

Teaching Points

  1. Virchow's triad explains VTE risk: stasis (immobility), endothelial injury (surgery), hypercoagulability
  2. D-dimer is sensitive but not specific; useful to exclude VTE in low-probability patients
  3. Submassive PE has RV dysfunction but stable hemodynamics; massive PE has hypotension
  4. The S1Q3T3 pattern and anterior T-wave inversions suggest right heart strain
  5. Provoked VTE (by transient risk factor) has lower recurrence risk than unprovoked VTE
  6. DOACs are now first-line for most VTE; advantages include fixed dosing and fewer interactions

All cases for this lecture as Markdown