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CHEST is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright 1993 by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692
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DIsCussIoN Pulmonary
aspiration of
actinomycosis
oropharyngeal
usually
material
occurs
in the
as a result
setting
of the
of poor
it is
Deep Venous
and Potentially
French, M.D.; M.D.
dental
invasive,
hygiene often
or oral mimicking
Lethal
and
to this
macroscopic
appearance.
Adrien
C. Bouchard,
pathogen rarely is reported. Ariel et al recently described five patients presenting with endobronchial actinomycosis presenting in a subacute fashion, similar to the presentation in our patient. Endobronchial infection is thought to be due to implantation of infected aspirated material, lymphohematogenous spread to the peribronchial region, or endobronchial implantation of infected secretions from draining cavitary lesions. Although the diagnosis of actinomycosis was presumptive since the cultures of all specimens were negative, this was not an unexpected finding in light of antibiotic therapy administered prior to bronchoscopy. In addition, the finding
of a sputum culture positive for H influenzae is common Coexisting in
The significance ofupper extremity deep venous (DVT) has been minimized in comparison to thrombosis, likely due to the erroneous belief quent pulmonary thromboembolism is rare. The of pulmonary thromboembolism originating in
extremity
catheters
veins
must
now
be
seriously
considered
medical instrumentation being performed more commonly in accessing the central venous system. It has been incorrectly assumed that the risk of pulmonary embolism was low due to the abundant collateral flow, and thus lack of stasis around an upper extremity even with venous occlusion. However, several studies, including a
recent prospective trial,
concluded that
and
pulmonary
embo-
Eikenella
lism
is not
be cultured
Even among immunocompromised hosts, such as patients on chronic steroid therapy or cancer chemotherapy, actinomycosis has not been shown to have an increased prevalence of infection. Actinomyces is a rare pathogen in the HIVinfected population. This is most likely due to the partial susceptibility of the organism to antibiotics commonly used to treat persons with AIDS such as trimethoprim-sulfamethoxazole, isoniazid, rifampin and the cephalosporins. Why this particular patient developed actinomycosis infection with endobronchial disease is unclear. Although his oral hygiene appeared to be maintained, there may have been
unsuspected aspiration of oropharyngeal secretions which
catheter-related
risk of subsequent pulmonary thromboembolism. We present an ifiustrative case documenting extensive pulmonary embolization that occurred following insertion of a central venous catheter and subsequent thrombosis of the right subclavian and innominate veins. With absolute contraindications to thrombolytic and anticoagulation therapy, prevention of further embolization
was
cava achieved filter. by percutaneous insertion of a superior vena
is at greatest
(Chest
1993;
103:1887-90)
subsequently led to endobronchial disease. The possibility that the endobronchial tissues may have been secondarily involved from a more distal infection, as seen in tuberculosis,
also must be entertained. The subacute initial lack ofresponse to orally administered presentation, antibiotics the and is
DVT
deep
venous
thrombosis;
SVC
superior
vena
cava
C
sions
omplications
categorized
of subclavian
into three main
vein
thrombosis
subgroups:
may
pulmonary
be
the development
spectrum consistent lesions with are
AIDS
of a new infiltrate
administered infection. this
while
receiving
a broadregimen
embolism, the postthrombotic syndrome, and venous gangrene. More common in the medical literature are discusrelated rare
of in discuss
antibiotic
to
the
postthrombotic of venous
vein to iiofemoral thrombosis
syndrome gangrene.
has thrombosis, been this
and Since
the the
mini-
extremely
occurrence
subclavian
Actinomycosis
also must
at the
be considered
of bronchoscopy
when infection.
obstructing
in a patient
significance mized
time
comparison
article
and a suspected
pulmonary
will
(DVT)
pulmonary
ofthe
REFERENCES
A, Talavera W, Rorat E, Salsitz E, Widrow C. Pulmonary actinomycosis in a patient with HIV infection. Mt Sinai J Med 1982; 49:136-39 2 Miracco C, Marmno M, Lio R, Cornetti M, Luzi P. Primary
endobronchial 3 Ariel E. noma. 4 Wasser the A, Breuer Endobronchial Chest LS, acquired BA, Shaw actinomycosis. R, Kamal N, actinomycosis Eur Respir simulating W. Endobronchial syndrome. BA, Greenberg Neck Surg Chest MS.
1 Klapholz
CASE
A 67-year-old
investigations
white
man
was
of progressively
1988;
Ben-Dov
I, Mogle
patient
patients
had bilateral
history He continued
adenocarcinoma
four
years
previous
admission.
to smoke
1991; 99:493-95
GW, Talavera immunodeficiency Hone
The
each
94:1240LT
that
failed
an in situ
44
5 Yeager
Bilaniuk
immunodeficiency Head
syndrome
1986; 112:1293-
re-
Arch
*From the Departments of Surgery (Drs. Black and Bouchard) and Radiology (Drs. French and Basuli), the Ottawa General Hospital and the University ofOttawa, Ontario, Canada.
Reprint requests: Dr. 10,53 Carling Avenue, Black, Ottawa, University Ontario, of Ottawa Heart Institute, Canada K1Y 4E9
CHEST
I 103 I 6 I JUNE,
1993
1887
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FIGURE
1. Superior
ofthe
the
confluence
There
is reflux
veins, contrast being injected. ofcontrast into the left innominate vein, not a filling from the right innominate vein (arrow) into the
consistent with thrombus.
The
catheter
is positioned
at
satisfacinnominate
placement
of the Findings
filter.
Pathologic
was extensive
A full autopsy
that recurrent
the
cause significant
a revision of the previous graft, and finally a right axillofemoral and femoropopliteal graft. The patient eventually underwent a right above-knee amputation. The patients postoperative course was
complicated by the development of gastrointestinal bleeding, con-
pneumonitis.
included
the
gestive
care failure
gram
heart
unit (ICU) prompted were
failure,
and
pulmonary
continued and showed
sepsis.
and scan a possible bilateral leg has of the was The and obtained femoral
During
progressive to rule
his intensive
respiratory out pulmonary angiodefects showed above-knee and was in the correction iliac then right for there a left vena femoral cavogram no
left
pleural metastases and mediastinal lymph node (2) a thrombotic state secondary to the pulmonary with recent massive pulmonary thromboemboli, mainly
and thrombosis resulting marked left leg or the
DISCUSSION
admission,
a ventilation-perfusion A venogram
of the filter and occlusion edema of the right arm; right lower extremity
thromboembolism. requested. The consistent evidence amputation, veins advanced was The the lature obtained superior presence suggestive as well approach; ventilation-perfusion with of
no DVT found
in the
stump.
pulmonary
A left patient
venogram
Recognition
The possibility of pulmonary thromboembolism originat-
DVT
1). This
a large
innominate magnification.
vein,
vena
the most
cava (SVC)
likely
source
of the pulmonary
24 mm emboli.
measured
Pulmonary
of bilateral
angiography
pulmonary
was performed,
Furthermore, carcinoma. bleeding
was a suggestion
Because
of extrinsic
of a recurrent
compression
bronchogenic
of the pulmonary
of a history
of recent
gastrointestinal
indicating
peared emboli
anticoagulant
to be the best from access superior vein orientation when patients ICU used condition to the surgical deteriorated originating introducer vein SVC
therapy,
option the and (Vena thrombus Tech) the to the introduction (apex in the inferior ward and
placement
in the inserted was set caudad), vena and eventually was course
of an SVC
the right lungs through of the to place from the innominate in the
filter
apvein.
A filter
left femoral
third (Fig in the orientation The from his the of the correct
azygos to the
2). A jugular
improved, he
transferred
for convalescence.
Unfortunately, of respiratory
FIGURE
condition
3. Postmortem
(arrow) and occlusion
specimen
ofthe
demonstrating
SVC.
thrombosis
of the
failure 1888
secondary
to severe
pulmonary
sepsis
weeks
following
filter
Upper Extremfty
Deep
Venous Thrombosis
(B!ack et a!)
Downloaded from chestjournal.chestpubs.org by guest on November 16, 2009 1993 American College of Chest Physicians
ing
from
the
upper
extremity
veins
must
now
be
seriously
venous
nary
return, Insertion
megacava,
of pulmoextremity
considered with catheters and pacemaker hardware cornmonly being utilized in accessing the central venous system. It is now well established that pulmonary embolism frequently presents in an asymptomatic fashion.s.4 It is therefore not surprising that 30 percent ofthose with angiographically proven pulmonary ernboli have a normal lower extremity venogram.5 Etissible explanations for the latter finding could include either (1) embolization of all thrombi to the pulmonary circulation or (2) emboli derived from a source other than the deep veins of the legs, le, the deep veins of the upper extremity.3 Source Our case provides direct evidence that DVT ofthe upper extremity may be the source of lethal pulmonary thromboembolism. Thrombosis ofthe subclavian veins may be either primary or secondary. The condition is rare, occurring in less than 2 percent of all cases of venous occlusion prior to 1967.#{176} Undoubtedly, the incidence has risen with more frequent use of these veins for treatment of a variety of medical problems. Primary thrombosis generally occurs following exertion, as exemplified by the high occurrence of cases in the dominant upper extremity. Approximately 25 percent of cases of primary thrombosis arise spontaneously without a recognized predisposing event.#{176} Secondary thrombosis, which occurs more often, can occur due to local sources of inflammation and/or compression, le, scierosing intravenous solutions, foreign bodies such as catheters, and anatomic variations at the thoracic outlet. Clots have been found to form at the site of venipuncture and extend along the venous catheter. Swinton et al suggested that pulmonary embolism was more frequent and severe in patients with secondary thrombosis ofthe upper extremities. Hypercoaguability states, a manifestation of serious
disorders,
thromboembolism
veins.
circumstance It is hoped
in
caval
filter
in the latter
and perhaps
venography,
the
near
future
will
duplex occurs
and
whenever
light
reflection
pulmonary
rheography,a thromboembolism
ofupper
placement
extremity
of venous
venous filters
further
access. in humans
protection
performed
pulmonary
recurrent
other
modes
of therapy Information
Technkal
Insertion
SVC Filter
Prior to the insertion of the filter, the distance between the left groin and the SVC should be measured, using a guide wire clamping technique. In our case, this indicated that the introducer was of adequate length. It should be noted that in our patient, who was of average height, the total length of the introducer had to be inserted in order to
deliver suggest
longer
devices
the that
ifiter
to
the
desired
location.
We
therefore
170 cm
therapy astinal
massive
because bleeding
pulmonary
problem may preclude the use of thrombolytic of fear of excessive retroperitoneal medi-
or from
the
thromboembolism
should further The recent and vena caval filters may negate
occur.
insertion
site
CONCLUSIONS
preexisting
disease, such as neoplastic known to be associated with secondary markedly reduced survival. Treatment Unlike
treatment
systemic
are
thrombosis
well and a
the
rarer
sequelae
have yet
of upper
been advocated
extremity
for the
DV1
preven-
no
protocols
tion of recurrent pulmonary thromboembolism. Early yenous thrombectomy in the acute situation has been advocated in an attempt to prevent residual disability despite the initial effectiveness of anticoagulants.b0.h1l.19 4jtjc.#{231}gij lant therapy continues to be recommended solely or cornbined with surgery on the theoretical grounds of preserving venous collateral flow,#{176} thus possibly avoiding long-term disability. Fibrinolysis and anticoagulation therapies that seem most promising are likely to continue to serve as the primary noninvasive modalities prior to surgical correction ofany existing abnormalities. Blinded by Virchows identification that the lower limbs were the major anatomic source of pulmonary thromboembolism, technical advances and medical therapies for the prevention of further pulmonary thromboembolism have long centered around the inferior vena cava as the major avenue of subsequent thromboembolism. When contemplating the use of an inferior vena caval filter, the surgeon/ invasive radiologist must be aware ofnot only the anomalous
A recent prospective trial concluded that pulmonary embolism is not a rare complication in upper extremity DVT, and catheter-related VFseems to be at the greatest risk.2 Upper extremity DVT must now be taken seriously as a harbinger of possible pulmonary thromboembolism. As illustrated in our case, a combination of risk factors, ie, hypercoagulability secondary to recurrent pulmonary carcinoma, and the cannulation of the central veins made embolization from an upper extremity DVT possible. With the systemic and pulmonary venous systems being accessed
increasingly for a multitude of invasive diagnostic and
therapeutic
possibly
procedures,
newer less
upper
invasive
extremity
modalities
venography
should be
and
contem-
plated whenever pulmonary thromboembolism occurs in the presence ofupper extremity venous access. The insertion of an SVC ifiter may provide further protection against recurrent nulmonarv embolism when other modes of theranv
are contrarndicated.
REFERENCES
vein
thrombosis:
a continuing
M, Lafoz E, Ruiz J, Valls R, Alastrue A. Upperextremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest 1991; 99:280-83 3 Harley DP, White BA, Nelson RJ, Mehringer CM. Pulmonary embolism secondary to venous thrombosis of the arm. Am J Surg 4 Monreal 1984; M, 147:221-24 Rey-Joly C, Ruiz
J,
Salvador
R, Lafoz
E, Viver
E.
CHEST
I 103 I 6 I JUNE,
1993
1889
Downloaded from chestjournal.chestpubs.org by guest on November 16, 2009 1993 American College of Chest Physicians
pulmonary is it useful
in patients a lung
30:194-07
with
deep
vein
385-86 28 Hoffman MJ, by MR. superior Surg EW, 1985; Greenfield superior Etheridge vena 2:794-98 GP Harrington in the superior vena Schoettle caval U. vena JC, Central cava Crete venous Greenfield SI, septic filter thrombosis and U. venous Experi-
scan
to rule
out
this PA,
and
J Cardiovasc
Hirsh
managed
PE, Ockelford
lung scanning, 29 Langham mental Vase 30 Owen
J,
Carter
thrombectomy:
a case report.
J Vase Surg
1986; 4:606-11
Greenfield
et al. Pulmonary
venography
angiography,
for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med 1983; 98:891-99 6 Barker NW, Nygaard KK, Walters W, Priestley JT. A statistical study of postoperative venous thrombosis and pulmonary em-
placement
filter.
bolism:
IV
location Clin PW
and
of a Surg
1941;
16:33-37
subclavian history Arch Bernstein obstruction. of Surg EF. Sur-
Surg
1967; thrombosis
Grifliths
Chandler
and
JG,
Tegtmeyer
brachiocephalic
carinii
of
M.D.; M.D., FC.C.P
1977;
11 Swinton
axillary 12 Kakker
in the upper extremity (Pagetsyndrome). mt Abstr Surg 1949; 88:89-127 NW Jr, Edgett JW Jr. Hall RJ. Primary subclavianthrombosis. Howe Circulation AN, 1968; 38:737-45 JTC, Clarke MB. CI, Nicolaides Benney
Venous
obstruction
vein VV
andJeffrey
A. Golden,
13
14
15
16
Deep vein thrombosis of the leg: is there a high risk group? Am J Surg 1970; 120:527-30 Pineo GF, Brain MC, Gallus AS, Hirsh J, Hatton MWC, Regoeczi E. Tumors, mucus production and hypercoagnlability. Ann NY Acad Sci 1974; 230:262-66 Carson JL, Kelley MA, DuffA, WegJG, Fulkerson WJ, Palevsky HI, et al. The clinical course ofpulmonary embolism. N EngI J Med 1992; 326:1240-45 Drapanas T, Curran WL. Thrombectomy in the treatment of effort thrombosis ofthe axillary and subclavian veins. J Trauma 1966; 6:107-19 Mahorner H, Castleberry JW, Coleman WO. Attempts to restore function in major veins which are the site ofmassive thrombosis. Ann Surg 1957; 146:510-22 JT, DeWeese JA. Effort thrombosis 11:923-30 VF, DaRocha E. Thromboof the axillary and
carinli pneumonia (PCP) is the most common complication ofAIDS and is typically diagnosed by the identification of P carinli organisms in sputum, bronchoalveolar lavage fluid, or tissue obtained with transbronchial biopsy. We describe two H1V-seropositive patients with pleural effusions in whom the diagnosis of P carinli infection was made by examination ofpleural fluid. Pleural effusions associated with PCP are very unusual but can provide a source ofthagnostic material particularly in those my patients who have development of a spontaneous pneumothorax and require chest tube insertion. (Chest 1993; 103:1890-91)
Pneumocystis
pulmonary
17 Adams
subclavian
18 Ochsner
veins.
J Trauma
M,
1971; DeCamp
AFBacid-fast
man
bacteria;
A, DeBakey
embolism: analysis ofcases at Charity Hospital in New Orleans over a 12-year period. Ann Surg 1951; 134:405-19 19 Adams yI McEvoy RK, DeWeese JA. Primary deep venous thrombosis ofupper extremity. Arch Surg 1965; 91:29-42 20 Marks J. Anticoagulant therapy in idiopathic occlusions of axillaryvein. BMJ 1956; 1:11-13 21 Wilson JJ, Zahn CA, Newman H. Fibnnolytic therapy for idiopathic subclavian-axillary vein thrombosis. Am J Surg 1990;
159:208-11 22 Colman thrombosis: 11W Hirsh basic Co, M,
virus; avium
H1Vh1 dehydrogenase;
Pneumocyatis
PneunwcystLI
percent
syndrome
illness.
described
pleural is very
carinii pneumonia (PCP) occurs in 80 of all patients with acquired immunodeficiency (AIDS) at some time during the course of their Although spontaneous pneumothorax is a well-
J,
Marder
VJ, Salzman
principles Creger
JB Lippincott
23 Rubenstein catheter-induced 1980; 24
complication
space causing uncommon. is
of PCP,
inflammation In fact, it has
actual
involvement
of the
subclavian SZ. and Lutter Massive deep KS, venous Moeller scanning. 199-200
thrombosis.
embolism.
Med
140:1370-71
Pulmonary WB SaunPhiladelphia: Hasselfeld extremity KA, venous
present, it is probably indicative of a disorder other than PC? In this article, we describe two patients in whom the diagnosis of P carinii infection was made by evaluation of pleural fluid. To our knowledge, identification ofPcarinii in pleural fluid has not been described previously.
effusion
Co, 1985;
McKenna
25
KerrTM,
Roedersheithrombosis
CASE
CASE
1 man with
REPORTS
mer RL,
diagnosed 26 Mukherjee
Am J Surg 1990; 160:202-06 CA, Sado Maj AS, Bertoglio MC. Use oflight reflection rheography for diagnosis ofaxillary or subclavisa venous thrombosis. Am J Surg 1991; 161:651-56 27 Pais SO, De Orchis DF, Mirvis SE. Superior vena caval placement of a Kimray-Greenfield filter. Radiology 1987; 165: by duplex D, Andersen
A 23-year-old
weeks
hemophilia cough,
A was dyspnea
examined on exertion,
because fevers,
of 2 and
of a nonproductive
*From
Francisco.
the
Pulmonary
Division
University
of California
at San
1890
Diagnosis
of P carinil Infection
by Identification
of P carin!!
fri
Pleural
Fluid
(Schaumberg
et a!)
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Upper extremity deep venous thrombosis. Underdiagnosed and potentially lethal. M D Black, G J French, P Rasuli and A C Bouchard Chest 1993;103; 1887-1890 DOI 10.1378/chest.103.6.1887 This information is current as of November 16, 2009
Updated Information & Services Citations Updated Information and services, including high-resolution figures, can be found at: http://chestjournal.chestpubs.org/content/103/6/1887 This article has been cited by 13 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/103/6/1887#relate d-urls Freely available online through CHEST open access option Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestjournal.org/site/misc/reprints.xhtml Information about ordering reprints can be found online: http://www.chestjournal.org/site/misc/reprints.xhtml Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online article figure for directions
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