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 .