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Challenging Cases

Challenging Cases. 71-year old male. Admitted with worsening shortness of breath PMHx : Severe COPD, A.Fib , CHF/ischemic, PE On long term anticoagulation with Pradaxa 150 mg twice daily. Compliant with medications. COPD exacerbation/pneumonia were diagnosed

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Challenging Cases

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  1. Challenging Cases

  2. 71-year old male • Admitted with worsening shortness of breath • PMHx: Severe COPD, A.Fib, CHF/ischemic, PE • On long term anticoagulation with Pradaxa 150 mg twice daily. Compliant with medications. • COPD exacerbation/pneumonia were diagnosed • Treatment for both issues was started • Labs on admission: • Hgb 12.7, WBC 15K, Plts 154K • Creatinine 1.2 Metabolic panel otherwise normal • CXR – b/l infiltrates consistent with pneumonia

  3. Additional tests • Lower extremity swelling was noted on hospital day #2 • Lower extremity venous doppler : acute DVT in right posterior tibial and pernoneal veins

  4. Question 1 • New VTE in a patient who is being treated with Pradaxa. What additional diagnostic tests would you recommend?

  5. Results: • D-Dimer is negative • Pradaxa was stopped • LMWH was started • Lupus anticoagulant is positive

  6. Question 2: • What are your plans regarding long term anticoagulation and with what agent?

  7. 51-year old female • Admitted with lower extremity swelling • Prior history of unprovoked PE one month ago • F/U CT confirmed clearance of PE 2 weeks prior to admission. Hypercoagulableworkup negative at outside hospital • Maintained on Xarelto 20 mg daily and compliant with therapy • Doppler study – acute DVT in left posterior tibialvein • Labs on admission: • Hgb 10.8, WBC 7.6K, Platelets 206K • INR 1.4 PTT 33 • Metabolic panel WNL

  8. Now what? • New VTE despite Xarelto?

  9. Hospital course • Started on therapeutic Lovenox q 12 hours. D/C Xarelto • Hospital day 2 – worsening chest pain, SOB • EKG: OK • Echo reveals large pericardial effusion • IVC filter placed prior to pericardiocentesis

  10. Thoughts please!??

  11. Hospital course continued • CT chest – bilateral PE, pleural effusion, mediastinaladenpathy, adrenal mass, apical mass/infiltrate • Now what??

  12. Findings • Pericardial fluid bloody with evidence of malignant cells (adenocarcinoma) in this patient with recent PE, acute DVT,IVC filter placement and now new evidence of malignancy…

  13. Questions…questions…. • How would you approach continued long term anticoagulation? For how long? With what agent? And what additional work up would you do?

  14. THANK YOU

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