Deep Vein Thrombosis, Septic Pulmonary Emboli and Methicillin-Resistant Staphylococcal Aureus Bacteremia Complicated by a Furuncle in a Child

Staphylococcal aureus infection in children is a major public health problem globally. It causes a varied spectrum of clinical disease including bacteremia, endocarditis, skin and soft tissue infection, pleuro-pulmaonry and osteo-articular infection. Deep vein thrombosis (DVT) is a known complication of staphylococcal infection. We report a case series which included, 10-year old boy developed DVT, septic pulmonary emboli and Methicillin-resistant Staphylococcal aureus (MRSA) bacteremia following a furuculosis and 13 year old girl with thrombosis of internal and external jugular vein, cavernous sinus with pulmonary emboli and MRA bacteremia. Both patients are previously healthy showed complete recovery after aggressive appropriate antibiotics, anticoagulants and supportive care. The high index of suspicion of DVT in MRSA infection is needed, prompt diagnosis and aggressive appropriate therapies improve the outcomes and minimize the complications.

Cerebral Venous Sinus Thrombosisin the Setting of an AVMWhile on Anticoagulation: A Case Report

Objective: To increase the awareness of neurological complications of arteriovenous malformation (AVM) due to obstruction of the venous drainage despite being on anticoagulants. Background: Cerebral AVMs are high-flow intracranial vascular malformation comprised of feeding arteries, a nidus of vessels with intervening brain parenchyma through which arteriovenous shunting occurs and dilated draining veins allowing significant hemodynamic gradient without an interposed resistance. Venous drainage stenosis or occlusion will increase the hemodynamic pressure gradient within the AVM compartments and potentially lead to redistribution of flow resulting in cerebral venous sinus thrombosis or hemorrhagic stroke from nidus rupture. This effect might be worsened in the presence of a generalized hypercoagulable state causing microvascular injury and thrombosis;despite adequate anticoagulation therapy. Design/Methods: N/A Results: 66-year-old obese woman with history of atrial fibrillation, coronary artery disease, diabetes, hypertension, hyperlipidemia, prior stroke, small left frontal AVM diagnosed on conventional angiogram and recent COVID-19 infection presented to our comprehensive stroke center with seizures and right hemiparesis. MRI brain showed T2/FLAIR hyperintense lesion in the left frontal/parasagittal region with an extensive vasogenic edema, heterogeneous diffusion restriction, and gyriform contrast enhancement. Conventional angiogram showed AVM without nidus opacification but with an associated mass effect correlating with parenchyma edema and early venous shunting. Patient was initially misdiagnosed as low-grade neoplasm although accurate diagnosis of left parasagittal frontal venous infarct in the setting of spontaneous venous thrombosis of left frontal AVM was made with conventional angiogram. Conclusions: Venous infarct due to CVST is a devastating complication of AVM. The hemodynamic pressure gradient within the AVM might play a larger role in contributing to hypercoagulable state within the venous system leading to cerebral venous sinus thrombosis despite patient being on therapeutic anticoagulation.

SUPERIOR VENA CAVA RESECTION FOR EXTENDED THYMIC EPITHELIAL TUMORS: SAFETY AND OUTCOMES ANALYSIS

TYPE: TOPIC: Disorders of the Mediastinum PURPOSE: Infiltration of superior vena cava (SVC) is not uncommon in stage III–IVa thymic epithelial tumours (TETs). SVC extent of resection is proportional to width of neoplastic invasion region. Aim: to assess the safety and long-term results of prolonged thymectomy for TETs with and without SVC resection. METHODS: Retrospective review of patients who underwent extended thymectomy for TETs during the preceding two decades, using STROBE method. Kaplan–Meier technique was used to calculate progression-free survival (PFS) and overall survival (OS). To evaluate the factors related to long-term outcomes, a backward stepwise Cox regression multivariate analysis was done. RESULTS: Between January 1998 and April 2019, 78 individuals received surgery for advanced-stage TETs (Masaoka-Koga stages III–IVa). 14 (17.9%) received thymectomy with SVC resection. At multivariate analysis, presence of thymic cancer (HR=2.26;95%CI=1.82–6.18;p=0.038) and SVC resection (HR=1.89;95%CI=1.11–3.96;p=0.041) were found to be unfavourable prognostic variables. All SVC resected patients had median OS=50 months (range: 5–207) and median PFS=31 months (range: 5–151). There was no statistically significant difference in OS (p=0.28) or PFS (p=0.32) between patients with and without SVC resection. CONCLUSIONS: SVC resection is a safe and successful surgery for re-establishing the continuity of the venous system that appears not to influence survival or disease recurrence. CLINICAL IMPLICATIONS: Surgical approaches vary considerably according to extent of SVC infiltration, and issues associated with SVC resection for TETs remain unresolved. SVC resection is a safe and effective operation that appears not to affect survival or recurrence. This surgical technique enables complete resection of locally progressed TETs, even following neoadjuvant treatment. DISCLOSURE: No conflict of interest to declare. This was submitted (ad accepted) in Chest 2020 Bologna withdrawn due to the COVID pandemic. KEYWORD: thymic epithelial neoplasm

A case of recurrent pulmonary embolism

Background: Nephrotic syndrome is known to be associated with hypercoagulable status. Pulmonary artery thromboembolism is one of the life- threatening complications in patients with nephrotic syndrome but rarely occurs before the diagnosis of nephrotic syndrome. Methods and Results: A 33-year-old man without any co-morbidities presented to a primary care clinic with sudden onset shortness of breath. An electrocardiogram showed sinus tachycardia with S1Q3T3. ECHO and CTPA revealed thrombi of the bilateral pulmonary arteries and he was COVID-19 negative by PCR analysis. Anticoagulant therapy was initiated immediately. Hypercoagulability workup showed normal levels of protein C, protein S, and AT III. He was ANA- and APLA negative and his homocysteine levels were normal. Lower limb Doppler showed multiple deep venous system thrombi. Three months following this episode, he presented with recurrence of acute worsening of breathlessness with pedal edema and abdominal distention. He was referred to our Cardiology emergency care. 2D Echocardiography showed classic Mc Connells sign with akinesia of RV free wall and RV systolic pressure of 60 mm Hg. CT pulmonary angiography definitively proved fresh (recurrence of) pulmonary embolism with large clots in both LPA and RPA and CXR showed classical signs of pulmonary embolism (Fig. 1). USG abdomen showed ascites, normal kidneys and no renal vein thrombosis. Laboratory examination showed he was COVID-19 negative again by PCR analysis. They also revealed low serum albumin (2.2g/dl) and nephrotic-range proteinuria (>10 gm in 24 hours) with transudative ascitic fluid. Since patient was on anticoagulation renal biopsy was deferred by the consultant nephrologist in view of possible bleeding complications. In view of possible primary membranous nephropathy, Serum Anti-Pla2r antibody was done which was strongly positive. The constellation of nephrotic-range proteinuria, pulmonary thromboembolic complications and associated serum anti-Pla2R antibody suggested primary membranous nephropathy. Immunosuppression was started as per modified Ponticelli regimen. Proteinuria resolved after three weeks and patient continues to be doing well on anticoagulation on oral VKA [Formula presented] Conclusion: Previous case reports of pulmonary artery thromboembolism associated with nephrotic syndrome are very few, particularly in adults. In the rare cases where they do occur, the patients initially present with the symptoms derived from nephrotic syndrome, unlike in our patient where the presentation was extremely rare and the investigation of the thromboembolic event led us “backwards” to the diagnosis of nephrotic syndrome. Awareness regarding the potential complications of hypercoagulable in nephrotic syndrome is thus essential.