Bilateral Pulmonary Embolism as Initial Presentation of Invasive Adenocarcinoma of the Colon




Burgess, Lauren
Gnasigamany, Jason
Salas, Gabriel
Subramaniam, Smita


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Background:Venous thromboembolism (VTE) is a frequently encountered diagnosis, and there are numerous genetic and acquired risk factors for this affliction. Thromboembolism due to hypercoagulability in cancer is well-known, and it is a common cause of death in these patients. Thrombosis represents the second most frequent cause of death in cancer patients, and cancer accounts for almost 20% of all VTE events. The highest incidence of VTE is in mucin-producing pancreatic, lung, and ovarian carcinomas. Although pulmonary embolism (PE) incidence in colon cancer is not as high as other malignancies, VTE may reflect more aggressive cancer and is a predictor of death within one year of diagnosis. In this report, we present a patient with syncope and anemia, a common scenario which uncovered the diagnosis of PE and subsequently colon adenocarcinoma. Case Information:A 43-year-old male presented with syncope, and had experienced fatigue, chest pain and dyspnea for a week. Aside from hypertension, there is no significant history. Vitals showed tachycardia, tachypnea and decreased oxygen saturation. Physical exam was unremarkable, and labs revealed severe microcytic anemia and a BNP of 2,285 ( Conclusions:Cancer patients treated with anticoagulation have lower mortality, and guidelines recommend low-molecular-weight heparin (LMWH) for cancer-associated thromboembolism. However, new evidence suggests that direct oral anticoagulants (DOACs) are reasonable alternatives. For our patient, we decided to give Apixaban for its ease of use over LMWH, and recent approval of DOACs is increasing the confidence regarding their safety. The unique aspects of this case involving anemia and bleeding risk with the need for anticoagulation raise the awareness of the varied co-existing disorders that can impact the diagnosis and treatment of cancer patients.