Multiple thromboembolism with multiple causes in a 69-year-old woman: a case report

Abstract

Introduction: Aggressive, recurrent embolisms require accurate etiologic diagnosis. We describe the case of a 69-year-old Italian Caucasian woman with recurrent arterial embolisms in whom several sources and triggers of thrombosis were detected.

Case presentation: The patient, a 69-year-old Italian Caucasian woman, presented with a systemic embolism that was initially attributed to atrial fibrillation. The recurrence of embolisms despite anti-thrombotic therapy prompted a re-evaluation of the clinical presentation. New potential causes of thrombosis emerged in this patient, including thrombocytosis associated with the JAK2 V617F mutation and the very rare mural thrombosis of the descending aorta. A mural thrombus in the pulmonary artery was detected contiguous with the aortic mural thrombosis, raising the possibility of a clinically silent ductus Botalli as the initiating event. The patient was treated with warfarin, aspirin, hydroxyurea, and surgery.

Conclusions: The diagnosis was achieved via systematic use of imaging procedures and reconsideration of blood tests performed to explore the diagnosis of thrombosis. This allowed a deeper and more detailed analysis of the case beyond the conventional approach, which would have aimed to identify one cause for the condition at hand, in this case, atrial fibrillation. The broader approach that we used resulted in the diagnosis of multiple embolisms from multiple sites and multiple causes.

Figure 1

A trans-esophageal echocardiographic scan showing an intra-luminal pyramidal lesion 1.4 cm×1.5 cm in size with an irregular surface on the anterior wall of the descending aorta (arrow).

Figure 2

A computed tomography slice of the thorax showing a mural aortic thrombus in the anterior wall of the descending aorta and a mural thrombus in the left pulmonary artery localized in close proximity to the aortic thrombus.