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Washington University Experience | VASCULAR | Infarct - Embolic | 23A0 Case 23 History
Case 23 History ---- The patient was a 70-year-old woman with a clinical past medical history of hypertension, systemic lupus erythematosus/discoid lupus erythematosus, and stage IV non-small cell lung cancer (status post chemoradiation and therapy). She presented to the ED at BJH for chronic (>1 month) bleeding following a dental extraction. Management over this period included transfusions and tranexamic acid. She had seen an oral surgeon on the day of presentation and had a large clot removed over the procedure site which resulted in worsening of her oral bleeding. Her labs showed: hemoglobin 8.2 g/dL, platelets 41 K/cumm, white blood cells 18.1 K/cumm. She was admitted to the Medical Intensive Care Unit (MICU) due to multifocal pulmonary emboli with concern for right heart strain and a possible malignant pericardial effusion on imaging. A transthoracic echocardiogram demonstrated a massive echodensity occupying the entire right ventricle thought to represent a thrombus. Management of her massive pulmonary embolism in the setting of thrombocytopenia complicated her therapy requiring a multidisciplinary approach. She was transferred from the MICU to the regular floor on 4/3. On 4/6, she developed a facial droop and left-sided weakness. Imaging showed new multiple foci in the gray-white matter junction of both cerebral hemispheres with surrounding vasogenic edema thought to represent hemorrhagic metastases. The clinical team favored hemorrhagic conversion of ischemic infarcts in the setting of anticoagulation as the source of the hemorrhages. On 4/7, she had an increased oxygen requirement and the decision was made to switch her code status to comfort care. She continued to have respiratory distress and died on April 9th, three weeks after admission.
