Case description
39 years old female presented with fever and shortness of breath for 14
days for which Total leucocytic shift 16 with shift to the left
,hemoglobin 9.5 MCV 69 ,CRP 161 ,chest X ray was free on admission , ECG
showed normal sinus rythm ,Echocardiography showed from right atrial
mass 2.7x1.9 cm ,moderate mitral and tricuspid regurgitation second day
after admission she started to suffer from pain and swelling of both
upper limb .Duplex Upper limbs revealed bilateral total occlusion of
subclavian ,axillary and brachial veins .Proximal part of right IJV was
totally occluded and left side was partially occluded . By examination
her blood pressure was 120/60 ,regular heart rate and rythm and oxygen
saturation 97% her neck showed visible dilated non pulsating veins
.cardiovascular exam showed pansystolic murmur over apex with no thrill
and another at lower part of sternum increases with inspiration .lung
auscultation showed diminished air entry at the right base .
During hospital stay lupus anticoagulant and anticardiolipin IgM were
positive, work up against infective endocarditis was done to exclude
secondary infection of right atrial mass and it was negative ,tumor
markers were negative , CT chest revealed right sided pleural
effusion,left lower lobe consolidation ,enlarged pretracheal
,supracarinal and aortocaval lymph nodes. TEE and CMR revealed right
atrial mass 2.7x2.9x 1.7 cm most likely thrombus and another mass in
right atrial appendage 1.0 x0.7x0.7cm, moderate mitral and tricuspid
regurgitation ,pulmonary hypertension ,patent non occluding thrombi
within SVC.
Patient underwent venous angiography for which catheter was inserted
through venous access to right cephalic vein and 1.5 million IU of
streptokinase was given and then she was maintained on heparin infusion
with adjustment to aPTT 50-70 , venography was done and revealing no
improvement so a decision was given to give second dose streptokinase on
fifth day she was given second bolus 250,000 and maintained on 100,000
IU /hour for 10 hours stopped due to fever(drug reaction), patient
underwent venous angiography follow up which revealed marked improvement
in venous blood flow .she was discharged home safely on aspirin 75 mg
once and warfarin with proper adjustment to target INR .