A 52-year-old woman with a history of dyscal hernia, hypertension and anxiety-depressive syndrome came to the emergency department of our center for chest pain and sudden onset dyspnea.
Physical examination revealed the presence of a left supraclavicular disease of 1.5 cm, decreased pulmonary hair in the hemithorax and tumef, erythema and pain on the left lower limb positive lymphadenation sign.
Basal arterial gas was pH 7.41, pC02 33 mmHg and p02 64 mmHg.
Blood analysis showed normocytic normochromatic anemia, the rest of the parameters were normal.
The chest X-ray showed a moderate right pleural effusion and electrocardiogram showed sinus tachycardia.
A Doppler ultrasound of the lower limbs revealed left popliteal-moropopliteal thrombosis and, when pulmonary thrombo-embolism was suspected, a computed tomography (CT) of the right middle pulmonary artery showed multiple descending pulmonary effusions, confirming a bilateral pleural effusion.
With the diagnoses of deep venous thrombosis and pulmonary thromboembolism of probable neoplasic origin, anticoagulant treatment was initiated and the patient was admitted to Internal Medicine to complete the study.
A transthoracic echocardiogram revealed left ventricular hypertrophy with good systolic function, tricuspid regurgitation and a systolic pulmonary artery pressure of 50 mmHg, as well as moderate pericardial effusion.
Proteinogram and thyroid hormones were normal.
Tumor markers in peripheral blood showed the following values: Beta 2-microglobulin 3.84 mg/L, AFP 0.8 IU/mL, CEA 27.5 ng/mL, CA 19.9 264 U/13mL,
An abdominal-pelvic CT scan showed the presence of multiple retroperitoneal lymph nodes, bilateral retrocrural and iliac veins suggestive of lymph node metastases or lymphomas, as well as left iliac vein thrombosis.
Upper gastrointestinal endoscopy and mammography were normal.
A biopsy of the left supraclavicular lymphadenopathy was performed and the pathological study showed lymph node metastases from adenocarcinoma.
Immunohistochemical study showed positivity for cytokeratins (CK) (AE1-AE3, CAM 5.2 and CK7), CA 125, CA 19.9 and negativity for CK20 and AL100 follicular origin together CD10, CD10
The patient's general condition progressively worsened without chemotherapy and developed refractory respiratory failure, dying four weeks after diagnosis.
Necropsy was requested but was not granted by the family.
