Abstract The patient is a 67-year-old female with newly diagnosed stage IV lung adenocarcinoma with high PD-L1 expression, who initially presented to the emergency department with acute on chronic hypoxemic respiratory failure (AHRF) requiring high-flow nasal cannula. The AHRF was found to be secondary to pulmonary embolism (PE) and post-obstructive pneumonia in the setting of lung cancer.Chest X-ray revealed a right lung whiteout, and CTA of the chest demonstrated a left pulmonary embolus with a saddle embolus at the distal left main pulmonary artery, minimal right heart strain, multifocal adenopathy, worsening dense consolidation in the right lung, and a few ground-glass opacities in the left lung. The patient’s PE had a shock index 1, consistent with low-risk submassive versus high-risk submassive PE.During the initial hospitalization, the patient was also noted to be bacteremic, requiring IV vancomycin and piperacillin-tazobactam (Zosyn). She was eventually discharged on enoxaparin (Lovenox) and a prednisone taper.The patient subsequently re-presented to the emergency department with recurrent AHRF, reporting noncompliance with Lovenox. Evaluation revealed a malignant pleural effusion and imaging findings consistent with post-obstructive pneumonia. During this admission, she developed a 50% decrease in platelet count and, given her intermediate risk for heparin-induced thrombocytopenia (HIT), anticoagulation was switched from a heparin infusion to fondaparinux for management of her DVT/PE.A PleurX catheter was placed, and 1.5 liters of pleural fluid were removed. During hospitalization, the patient developed altered mental status. CT head and CTA head/neck were negative for hemorrhage and large-vessel occlusion but were concerning for venous sinus thrombosis. Subsequent MRI brain and MR venography revealed multiple infarcts involving the left parietal lobe, posterior right parietal lobe, anterior left frontal lobe, and bilateral cerebellum. The imaging also demonstrated intracranial metastatic disease and thrombosis of the distal left transverse and left sigmoid sinuses.The patient’s case was reviewed by Interventional Pulmonology, Radiation Oncology, and Hematology/Oncology. Given the advanced disease and poor functional status, consensus among consultants was that hospice care would be most appropriate. After discussion with the family, the decision was made to transition the patient to comfort care measures. This abstract is funded by: None
Tumpudi et al. (Fri,) studied this question.
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