A 35-year-old patient had no relevant past medical history.
He came to the emergency room for presenting back pain and progressive dyspnea for two weeks.
Physical examination revealed a hard, non-painful tumor in the right testicle of 2 cm. Chest radiography showed multiple metastatic pulmonary nodules.
Due to the suspicion of testicular germ cell tumor, analgesia was requested and a study was requested using tumor markers and toxico-abdominal-pelvic CT.
Orchiectomy was scheduled for the next week.
Before the date of the surgical intervention the patient came to the emergency room for pain and increased perimeter of the right lower limb.
The examination revealed edema in all right lobes, positive Homman's sign, peripheral arterial pulses and normal color.
Multiple bilateral pulmonary nodules, mediastinal adenopathies, and a retroperitoneal adenopathic mass encompassing the vena cava and the aorta, femoral neck and colapse were observed on toac-abdominal-pelvic CT.
Tumor markers alpha-fetoprotein and HCG were normal, LDH increased (2,900 mU/ml).
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Clinical features of right lower limb DVT were established and treatment with low molecular weight heparin was initiated at therapeutic doses.
During the following hours, the patient presented a rapid worsening of edema, pain, and the appearance of a bluish coloration, with clear signs of phlegmasia cerulea dolens.
Thrombolysis with rtPA and anticoagulation with heparin sodium IV were decided.
The dose administered from rTPA: 100 mg to 50 ml/h to 2 h.
The following analytical pre-thrombolysis controls were performed: hemoglobin (Hb), hematocrit (Hto), fibrinogen (D-D) and fibrinogen (D-D) and immediately after it with: TTD, Hto and D.
If the aPTT is less than 80 seconds, bolusless sodium heparin infusion (24,000 IU in 500 cc of saline solution at 21 ml/h) is initiated; if the ATTT is more than 80 seconds, it should be repeated.
After the end of the thrombolysis, the patient presented decreased edema, disappearance of the blue coloration and disappearance of the pain.
The pathology report of orchiectomy was a testicular seminoma that respected the albuginea and the cord is noticeable.
Patient with advanced seminomatous testicular tumor with characteristics of good prognosis, chemotherapy was initiated with BEP scheme a total of 3 cycles, and continued anticoagulation therapy with warfarin.
After completing treatment, the assessment was complete radiological response with LDH normalization.
Regarding the right atrium, currently presents an increase in the perimeter at the level of the thigh with collateral circulation, but it can be normal and without pain.
During the follow-up, the patient presented several progress of disease that responded to chemotherapy treatment, but did not present problems in the consolidation, and had a normal life.
