Case Presentation:
An 18 year old man with a history of asthma presented to the ER complaining of sudden onset dyspnea and cough. Lung examination and a CXR were normal. He was given IV solumedrol and nebulizer treatments but did not improve however. Further history elicited mention of persistent right leg pain since two weeks after a long road trip. Subsequent spiral CT chest demonstrated extensive bilateral pulmonary emboli. IV heparin was commenced, and the patient intubated for worsening respiratory distress. He remained hypotensive despite aggressive resuscitation. Echocardiography confirmed acute RV failure. Emergent pulmonary artery embolectomy was performed but unfortunately the patient continued to decompensate and expired days later. Pathology specimens of the embolus showed chondrosarcoma. This is a rare case of a chondrosarcoma presenting as a fatal pulmonary tumor embolism.
Discussion:
Pulmonary embolism is a common disease associated with significant morbidity and mortality. Pulmonary embolism is commonly associated with thrombotic thromboembolism but in the setting of malignancy, embolism of the tumor itself can rarely cause pulmonary embolism. The incidence of pulmonary tumor embolism has been reported to occur in about 0.9 to 2.4% of patients with carcinomas. The majority of cases are associated with breast, lung, and gastric carcinoma. In this case, a chondrosarcoma resulted in a fatal pulmonary tumor embolus. There are few reported cases of chondrosarcoma causing tumor embolism in the literature. In most instances, the diagnosis was delayed and only discovered later. The clinical presentation of pulmonary thromboembolism and tumor embolism is very similar, most commonly dyspnea, cough, tachypnea, and tachycardia. These similarities make the antemortem diagnosis of pulmonary tumor embolism extremely challenging. Due to the high morbidity associated with delayed treatment, it is imperative that physicians keep the diagnosis in mind especially in those with known or suspected malignancy and refractory symptoms.
Conclusions:
Pulmonary tumor embolism is a distinct entity from thrombotic pulmonary embolism and should be considered in the appropriate clinical setting particularly when a patient does not improve with usual therapeutic strategies.