Case Presentation: A previously healthy and ambulatory 34-year-old diabetic man presented with left-sided scrotal and groin cellulitis and was admitted to the hospital for intravenous antibiotic therapy. He was placed on appropriate pharmacoprophylaxis for venous thromboembolic disease and was observed ambulating on the unit. Despite one week of appropriate antibiotic therapy, he continued to have fevers; he had no evidence of abscess or free air on serial pelvic imaging studies. On hospital day 8, an area of fluctuance was noted over the left groin, and a large abscess was drained at the bedside with resolution of his fevers.
On hospital day 9, the patient complained of acute dyspnea and lightheadedness while standing. He was anxious appearing, diaphoretic, and tachycardic, and his electrocardiogram demonstrated a new right bundle branch block. Several minutes later he became pulseless and he received advanced cardiac life support. Bedside echocardiography revealed right ventricular dilation. He received four cycles of cardiopulmonary resuscitation and two empiric doses of tissue plasminogen activator for suspected acute pulmonary embolism, which was confirmed by CT pulmonary angiography after return of spontaneous circulation. He remained hemodynamically unstable and underwent emergent pulmonary embolectomy with retrieval of a large clot from the main pulmonary artery. He ultimately recovered and was discharged with excellent neurologic and functional status. The patient and his family reported no known history of hypercoagulability or previous venous thromboembolic disease.
Discussion: This case illustrates an atypical presentation of venous thromboembolic disease, a disease commonly encountered by hospitalists. Despite standard prophylactic therapy and excellent baseline functional status, this ambulatory patient suffered a nearly fatal pulmonary embolus soon after drainage of a large groin abscess in the absence of other major risk factors. The close temporal relationship between drainage of this patient’s large abscess and his massive pulmonary embolus suggests that the abscess may have placed him at risk for deep venous thrombosis through venous stasis distal to the abscess site. Though not commonly considered a risk factor for venous thromboembolic disease, extrinsic compression of the iliofemoral venous system has previously been described as a risk factor for deep venous thrombosis in case reports. Importantly, this patient’s abscess was not visualized on serial imaging studies, which made it difficult to discern its anatomic location in proximity to the vasculature. It is unclear whether more extensive imaging (such as Doppler studies) of the lower extremity would have identified a deep venous thrombosis prior to the patient’s massive pulmonary embolus.
Conclusions: Even in patients considered low-risk for venous thromboembolic disease, it is important to consider local venous compression by a mass or fluid collection as a potential risk factor for incident deep venous thrombosis and pulmonary embolism, particularly prior to performing a procedure that may decompress adjacent venous structures. In patients scheduled for manipulation of such pelvic lesions, it is important to maintain a high index of suspicion for occult venous thromboembolism.