Case Presentation:
An 83‐year‐old‐active white man with a medical history of hypertension and osteoarthritis and 1‐month history of low back pain presented to the emergency department with a right intertrochantericfemurfracture. He underwent emergent open reduction and internal fixation (ORIF).
On postoperative day 1, the patient developed generalized, myotonic jerky movements associated with hypoxia and unconsciousness and was responsive to painful stimuli. He was treated fora seizure disorder and responded well but remained confused. Computed tomography (CT) of the head showed no acute stroke or mass lesion. A CT of the chest showed an irregular hypodense mass in the proximal thoracic descending aorta that was worrisome for a large thrombus and a small thrombus in the right internal carotid artery. A workup for cardiac ischemia revealed elevated troponin I. The patient was heparinized. Transesophageal echocardiography showed dilated cardio‐myopathy with a left ventricular ejection fraction of 15%‐20% and a large mobile mass in the aorta measuring 4.6 by 1.6 cm, probably representing thrombus. The excised portions of the femurfrom the ORIF showed metastatic sarcoma. We performed thoracic magnetic resonance angiography (MRA) that revealed a filling defect in the proximal descending thoracic aorta arising from the aortic intima consistent with a primary aortic intimal sarcoma. MRI of the spine revealed multiple lumbar metastases. The patient and his family decided on comfort care only, and the patient was discharged to an inpatient hospice, where he died shortly thereafter.
Discussion:
Intimal sarcoma of the aorta is a rare and aggressive tumor with a propensity to metastasize to bone and visceral organs including the liver, kidneys, adrenal glands, and lungs. Accurate diagnosis of these tumors is difficult because of their rarity, varying presentation, and different pathological subtypes. Usually, symptoms are a result of vascular occlusions, thromboemboli, and metastases. In most cases, diagnosis is established late in the course of the disease. If detected early, surgical resection of the tumor may prove curative.
Conclusions:
Thromboembolism is common in hospitalized patients, especially postoperatively, and in patients with malignancies. Intimal sarcoma, a rare tumor, may present with clinical features of thromboembolism. Therefore, it is important for clinicians to be aware of this rare disease as differential diagnosis of thrombus and be familiar with the appropriate diagnostic workup for patients for whom there is a high clinical suspicion of intimal sarcoma.
Author Disclosure:
A. Roy, None; E. Abate, None.