A 69-year-old male, former smoker for 3 years earlier (50 packs/year).
He was admitted due to dyspnea of one month of evolution, progressive until reaching minimal exertion and sometimes at rest, without orthopnea.
He did not report cough, expectoration or fever, but he lost 5 kg of weight.
He was being studied in the Urology Department due to occasional hematuria.
Physical examination revealed 88% oxygen saturation, mild tachypnea and mild tachypnea.
Cardiopulmonary auscultation revealed rhythmic heart sounds, without murmurs, 107 beats per minute and base teleinspiratory crackles.
Left supraclavicular and laterocervical adenopathies measuring 1-2 cm and hepatomegaly measuring 4 cm were observed. The lower limbs did not show edema or signs of deep venous thrombosis.
The tests carried out in the emergency department showed D-D pattern (26778 μg/g/dL), respiratory alkalosis with O2 saturation 92% and electrocardiogram with sinus tachycardia at 963.
The chest X-ray was normal.
With the suspicion of pulmonary thromboembolism (PTE), treatment with medication and enoxaparin was initiated at therapeutic doses.
Pulmonary perfusion/perfusion scintigraphy (VG/Q) was performed because it reported allergy to contrast agents, which resulted in low probability of ventilation.
Doppler ultrasound of the lower limbs ruled out deep venous thrombosis.
We reviewed studies in the Urology Department before admission and ultrasound of the urinary tract showed renal cysts and prostate.
Abdominal CT without contrast showed metastases, scarce ascites, retroperitoneal lymph nodes and lesions in the left renal pelvis suspicious for urothelial neoplasia.
Blood tests showed urea: 0.65 g/l; creatinine: 1.45 mg/dl; LDH 1059 U/L; alpha-2 globulin 19.3%; normal blood count: 841 hour; VSG 107 mm at a
Jaundice: > 100/field
Pending the performance of complementary tests, including new ultrasound of the urinary tract, transthoracic echocardiography and biopsy of supraclavicular lymphadenopathies, among others, the patient had fever; hemocultive and antibiotic treatment was initiated without empirical new chest.
There was an abrupt increase in dyspnea with tachypnea at 44 rpm and significant jugular engorgement, requiring oxygen at high flows.
He was transferred to the ICU and a few minutes later he suffered cardiorespiratory arrest with ineffective cardiopulmonary resuscitation maneuvers, dying on the 5 day of admission.
The autopsy revealed a 3 cm tumor in the renal pelvis, associated with multiple occupant lesions in the liver and conglomerates of pericreatic adenop appearance metastatic periclavicular, periaortic mediastinal.
Both lungs showed congestive appearance, but without macroscopic tumor lesions or signs of pulmonary artery thromboembolism.
Microscopically, it was found that the neoplasm was located in the renal pelvis and showed histological characteristics of micropapillary urothelial carcinoma.
Significant lymphovascular and perineural invasion was observed.
All conglomerates adenop and liver lesions were metastases of urothelial neoplasia.
The most relevant finding was the presence of extensive microvascular pulmonary embolism that affected most of the capillaries and blood vessels of medium caliber of both lungs, in many cases occupying more than 80% of the pulmonary capillary edema and, frequently, was associated with progressive pulmonary occlusion.
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Postmortem urine cytology was positive for urothelial carcinoma.
