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DOI 10.1378/chest.103.6.1887

1993;103;1887-1890ChestM D Black, G J French, P Rasuli and A C BouchardUnderdiagnosed and potentially lethal.Upper extremity deep venous thrombosis.

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distributedrights reserved. No part of this article or PDF may be reproduced orCollege of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. Allhas been published monthly since 1935. Copyright 1993 by the AmericanCHEST is the official journal of the American College of Chest Physicians. It

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DIsCussIoN

CHEST I 10 3 I 6 I JUNE, 1993 1887

Pulm onary actinom ycosis usua lly o ccurs as a resu lt o f thea sp irat ion of oroph aryngeal m ateria l in the sett ing of poo rd en tal hy g iene or o ra l traum a . W hen pa tho gen ic , it isinvasive, o ften m im ick in g a m alig nancy in p re sen ta tion andm acrosco p ic appearance . E ndobro nch ial d isease d ue to th isp ath ogen ra re ly is reported . A rie l e t a l recen tly desc rib edfiv e p atien ts p re sen tin g w ith en dob ro nch ia l ac tinom ycos isp re sen ting in a su bacu te fa sh io n , s im ila r to the p resen tatio nin ou r pa tien t. E ndobron ch ial in fect ion i s th ou gh t to b e d ueto im p lan tatio n of in fec ted asp ira ted m ate r ial, lym phoh e-m ato genou s sp read to the pe rib ro nch ia l reg ion , o r end o-b ro nch ia l im p lan tatio n of in fec ted sec re tion s from d ra in in gc av ita ry les ions.

A lthou gh the d iag nos is o f ac tin om ycos is w as presumptives ince the cu ltures of al l sp ec im ens w ere n ega tiv e, th is w a sno t an u nexpec ted find in g in ligh t o f an tib io tic the rap yadm in iste red prio r to b ron ch oscop y . In ad d ition , the fin d ingo f a spu tum cu ltu re po sit ive fo r H in flu en za e is comm on inth e se ttin g of A c tinom yces pu lm ona ry in fectio n . Coexist ingo rg an ism s such as fu sob ac te ria , s trep tococc i and E ikene llam ay be cu ltu red as w ell.

Even am ong imm uno com prom ised h osts , such as p a tien tso n chron ic stero id the rapy or cance r ch em othe rap y , ac tino -m ycosis h as not b een sh ow n to have an inc reased prev alenceo f in fectio n . A ctin om yces is a ra re pa tho gen in th e H IV -in fec ted popu la tion . T h is is m os t lik e ly due to the par t ia lsuscept ibil ity of the o rgan ism to an tib io tic s comm only usedto treat p erson s with A IDS s uc h a s t ri me th op ri m- su lf am et h-oxazo le , ison iaz id , rifam pin an d th e cep ha losp orins. W hythis p articu la r pa tien t d ev e loped actin om ycosis in fec tionw ith en dob ro nch ia l d is ea se is un clea r. A ltho ugh h is o ra lh yg ien e appea red to b e m a in ta ined , th e re m ay have beenunsu spec ted asp ira tion of o rophary ngea l sec re tions w h ichsubseq uen tly led to en dob ro nch ia l d isea se . Th e po ssib ilityth a t the en dob ro nch ia l tissues m ay have been second arilyin vo lv ed from a m ore d ista l in fectio n , a s seen in tu be rcu lo sis ,a lso m ust be en ter ta ined . T he subacu te p resen ta tion , thein itia l lack ofrespon se to ora lly adm in is te red an tib io tic s andthe d eve lopm en t o f a n ew in filtra te w h ile rece iv in g a broad -spec trum in trav en ous ly adm in is te red an tib io tic reg im en isconsis ten t w ith th is in fec tio n .

A ctinom ycosis a lso m ust be co nsid ered w hen obs truc tingle sions a re no ted a t the tim e of b ro nchoscopy in a pa tien tw i th A IDS and a susp ec ted p u lm ona ry in fec tion .

REFERENCES

1 K laph olz A , T alavera W , R ora t E , Sa lsitz E , W idrow C . P ulm onaryac tin om ycos is in a pa tien t w ith H IV in fe ctio n . M t Sina i J M ed1982 ; 49:136-39

2 M iracco C , M arm no M , L io R , C o rne tti M , L uz i P . Pr imaryendobro nch ia l act inom ycos is. Eu r R esp ir J 1 98 8; 1 :6 70 -7 1

3 A rie l A , Breuer R , Kama l N , Ben -Dov I, M og le P , Ro s e nmannE . E ndobron ch ia l a ctin om ycosis sim u lating bronchogen ic ca rci-n om a. Ch est 1991 ; 99:493-95

4 W asser LS , S haw GW , Ta lav era W . Endobronch ia l tub ercu lo sis inthe a cqu ir ed im munod ef iciency syndrom e. Ch est 1988; 94 :1240-44

5 Yeager BA , H one J, Wei sman BA , G reenb erg M S . B ilan iuk LTA ctin om ycos is in the acqu ired immunodef ic iency synd rom e re-la ted complex . A rch O to la ryn gol H ead Neck Surg 1986 ; 112:1293-95

Uppe r Ext remi ty Deep VenousTh rombos i s *Underd iagnosed and Po ten tia lly L e th a lM ic hae l D . B lack , M .D .; G ord j F ren ch , M .D .;P as teu r P ia su li, M.D. ; an d Adr i en C . B ou cha rd , M .D .The sign ificance o fupp er ex trem ity deep venous th rom bosis(DVT ) h as b een m inim ized in com parison to iio fem o ra lth rom bos is, like ly du e to th e e rron eo us b e lief th at su bse -qu en t p u lm ona ry th rom boem bolism is ra re . T he p ossib ilityof pu lm onary th rom boem bolism orig ina ting in the u ppe rex trem ity v ein s m ust now be serious ly con side red w ithcatheters an d m ed ica l in strum en ta tion being pe rform edm ore comm on ly in accessin g th e cen tra l v enou s sy stem . Itha s been inco rre ctly as sum ed tha t the risk o f pu lm ona ryembol ism w as low du e to the abundan t co llate ral flow , andthu s lack of stas is aro und an upper ex trem ity even w ithv enous o cc lusion . H ow eve r, s eve ral s tud ies, in clu d ing arecen t p rospec tive tria l, con clu ded tha t pu lm onary em bo-lism is no t a rare com p lica tion in u ppe r ex trem ity DV T .Sign if ican t ly , when com paring a ll sou rces o f seco nda ryupper ex trem ity DV T , ca th ete r-re la ted up per ex trem ityDVT is at g rea te st r isk o f subseq uen t p u lm ona ry th rom bo-em bo lism . W e p resen t an if iu strativ e case d ocum entingex ten siv e p ulm on ary em bolizat ion that occurred fo llow inginsertion o f a cen tral venou s ca the te r an d subsequen tth rombosis of the r igh t subc lav ian and inn om in ate ve in s.W ith abso lu te co n tra ind ica tion s to th rom bo ly tic an d an ti-coagu la t ion the rap y , p reven tion of fu r th e r embol iza t ionw as ach iev ed by p ercutaneous insert ion of a super ior v enacava fi lter . (C hes t 1 993 ; 1 03 :188 7-90 )

I DVT = d eep v enous th rombos is ; SV C supe rio r v ena cavaC om plicatio ns o f su bc lav ian v ein th rom bosis m ay beca tegorized in to th ree m ain su bgrou ps: p u lm onaryem bo lism , the p ostth rom bo tic sy ndrom e, and venous g an -g rene . M ore comm on in the m ed ica l lite ra tu re are d iscus -s io ns rela ted to th e p ostth rom botic sy ndrom e and th eex trem ely ra re o ccu rrence of v en ous g angrene . S in ce th esign ificance of sub clav ian ve in th rom bo sis has been m in i-mized in com parison to iiofem oral throm bo sis , th is ar tic lewil l di scuss th e sig n if icance o f d eep v en ous th rom bos is(DVT ) ofthe u ppe r ex trem ity and its re lev an ce to subseq uen tpulm on ary em bo lism .

CA SE REPORTA 6 7 -y e a r- o ld w hite m an w as adm itted to the h osp ita l fo r fu rth er

invest igat ions o f p rogre ssiv ely w or sen in g r igh t low er lim b claud i-cation . T h e pa tien t had b ila teral c lau dication for ap proxim ately si xyears . The pat ien ts h istory in clu ded a left th oraco tom y for abron ch ogen ic adeno carc inom a four years p rev iou s to h is cu rren thosp i ta l adm iss ion . H e continued to sm oke again st m edical adv ice.

The pa tien t h ad m ultip le a ttem p ted v ascu la r recons truc tio ns,each one u nsu ccessfu l u ltim ate ly due to th rom bos is . T he o pe ra tio nstha t fa iled w ere an in situ com posite fem orop op litea l b ypa ss graft,*F rom the D ep ar tm en ts o f Su rgery (D rs . B la ck and Bouch ard) andRad io lo gy (D rs. F ren ch an d B asu li), the O ttaw a G eneral H osp ita lan d th e Un ive rsity ofO ttaw a , O ntario , C anad a.

R e prin t r equ ests: D r . B lac k , U n ive rsity o f O ttawa H eart Ins titu te ,10 ,53 C a rlin g A ven ue , O tta w a , O n tario , C an ada K 1Y 4E 9

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T he possibility of pulm onary throm boem bolism originat-

1888 Upper E xtrem fty D eep V e n ou s T h r om b o si s (B!ack et a !)

F IG U R E 1. Super i or v ena cav ogram . T he catheter i s posi ti oned atthe conf l uence of the tw o innom inate v ei ns, contrast bei ng in j ected.T here i s ref l ux of contrast i nto the l ef t i nnom i nate v ei n, not a f i l l i ngdefect bulging from the r ight i nnom i nate v ei n (ar row ) i nto theproxim al SV C consistent w ith throm b us.

a rev i si on of the pr ev ious graf t, and f inal l y a ri ght ax i l l of em or al andf em oropopl i teal graf t. T he pati ent ev entual l y underw ent a ri ghtabov e- k nee am putati on. T he pati ent s postoperat i v e course w ascom pl i cated by the dev el opm ent of gastroi ntest i nal bl eedi ng, con-gesti v e heart f ai l ure, and pul m onary sepsis. D uri ng hi s i ntensiv ecar e uni t (I C U ) adm i ssi on, cont i nued and progressi v e r espi ratoryf ai l ure pr om pted a v enti l ati on-perf usi on scan to r ul e out pul m onarythr om boem bol i sm . A v enogram and a possi bl e pul m onary angi o-gram w er e r eq uest ed .

T he v enti l ati on-perf usi on scan show ed bi l ateral m i sm atch def ectsconsi stent w i th pul m onar y em bol i . A l ef t l eg v enogram show ed noev i dence of D V T B ecause the pati ent has a ri ght abov e-k neeam putati on, a tr anscatheter v enogram of the ri ght f em oral and i l i acv ei ns as w el l as i nf er i or v ena cav a w as obtai ned v i a a l ef t f em or alapproach; all w ere free from clot. T he fem oral catheter w as thenadv anced through the ri ght atri um and a superi or v ena cav ogr amw as obtai ned (Fi g 1) . T hi s r ev eal ed a l arge throm bus i n the ri ghti nnom i nate v ein, the m ost l ik el y sour ce of the pulm onary em bol i .T he superior vena cava (SV C) m easured 24 m m after correction form agni f i cati on. Pul m onary angi ography w as perf or m ed, conf i rm ingthe pr esence of bi l ateral pul m onar y em bol i . F urther m ore, therew as a suggesti on of ex tr i nsic com pressi on of the pulm onary v ascu-l ature suggesti v e of a recur rent bronchogeni c carci nom a.

B ecause of a hi story of recent gastr oi ntesti nal bl eedi ng contra-indi cati ng anti coagul ant therapy , pl acem ent of an SV C f i l ter ap-peared to be the best opti on f or protect i ng the l ungs f rom f urtherem bol i ori g i nati ng f rom the throm bus i n the ri ght i nnom i nate v ei n.

A filter introducer (V ena T ech) w as inserted through the existingl ef t f em or al v ei n access and the f i l ter w as rel eased i n the pr ox i m althi rd of the SV C superi or to the ex pected course of the azy gos v ei n(F i g 2). A j ugul ar v ei n i ntr oducti on set w as used to pl ace the f i l teri n the correct ori entati on (apex caudad), ie , opposi te to the f i l ter sor i entati on w hen used i n the i nf eri or v ena cav a.

T he p atien ts con dition im p roved, and h e w a s later tran sferredf rom the I CU to the surgi cal w ar d f or conv al escence. U nf ortunatel y ,hi s condi ti on deteri orated and he ev entual l y di ed of respi r atoryf ai l ur e secondary to sev ere pul m onary sepsi s w eek s f ol l ow ing

F IG U R E 2. Posteroanter i or chest radi ograph dem onstrat i ng sati sf ac-tory f i l ter posi ti on j ust i nf eri or to the conf l uence of the i nnom i natev ei ns (arro w) .pl acem ent of the f i l ter.Pa tho log ic Findings

A f u l l autopsy dem onstrated that the i m m edi ate cause of deathw as ex tensi v e bi l ateral pneum oni ti s. Further si gni f i cant f i ndi ngsi ncl uded the f ol l ow i ng: ( 1) recurrent adenocarci nom a of the l ef tl ung w i th l ef t pl eural m etastases and m edi asti nal l y m ph nodei nv ol v em ent; (2) a throm boti c state secondary to the pul m onarym al i gnancy w ith recent m assi v e pul m onary throm boem bol i , m ai nl yi n the ri ght l ung, and throm bosi s of the f i l ter and occl usi on of theSV C (Fig 3) w ith resulting m arked edem a of the right arm ; and (3)no D V T f ound i n the l ef t l eg or the r i ght l ow er ex trem i ty stum p.

Recogn it ionDISCUSSION

F IG U R E 3. Postm or tem speci m en dem onstr ati ng throm bosi s of thef i l ter ( arrow ) and occl usi on of the SV C .


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CHEST I 10 3 I 6 I JUNE, 1993 1889

i ng f rom the upper ex trem i ty veins must now be seriousl yconsidered w i th catheters and pacemaker hardware corn-monly being uti l i zed in accessing the central venous system .I t is n ow w ell est a b lish ed th a t p u lm on a r y em b olism fr e-q uent ly p resent s in an asy mptom ati c f ashi on.s.4 I t i s t h er e fo r enot surpri sing that 30 percent of those w ith angiographical l yproven pulmonary ernbol i have a normal lower ex trem i tyvenogram.5 Eti ssible explanations f or the latter f i nding couldi nclude ei ther (1) embol i zati on of al l thrombi to the pulmo-nary ci rculati on or (2) embol i der i ved f rom a source otherthan the deep veins of the legs, le , the deep veins of theupp er ex tr em i ty .3SourceOur case prov ides direct ev idence that D V T of the upper

ex trem i ty may be the source of lethal pulmonary thrombo-embol i sm . Thrombosis of the subclav ian veins may be ei therprimary or secondary . The condi ti on i s rare, occurri ng inless than 2 percent of al l cases of venous occlusion pr ior to1967.#{ 176} U ndoubtedl y , the inci dence has risen w i t h moref requent use of these veins f or treatment of a variety ofm edi cal probl em s. Primary thrombosis general l y occursf ol l ow ing exerti on, as exempl i f i ed by the high occurrence ofcases i n the dom inant upper ex trem i ty . A pprox imatel y 25percent of cases of pr imary thrombosis arise spontaneouslyw i thout a recognized predisposing event.#{ 176} Secondarythrombosis, w hich occurs more of ten, can occur due to localsources of inf l ammation and/or compression, le , scierosingi ntravenous soluti ons, f oreign bodies such as catheters, andanatom ic variati ons at the thoraci c outlet. C lots have beenfound to form at the si te of venipuncture and ex tend alongthe venous catheter. Sw inton et al suggested that pulmo-nary embol i sm was more f requent and severe in patientsw i th secondary thrombosis of the upper ex trem i ties. H yper-coaguabi l i ty states, a mani f estation of seri ous preex i sti ngsystem ic disease, such as neoplasti c disorders, are w el lknown to be associ ated w ith secondary thrombosis and amarkedly reduced surv i v al . Treatment

Unl i ke the rarer sequelae of upper ex trem i ty DV1 not r ea tm en t p r o tocols h a ve ye t b een a d voca t ed for t h e p r even -ti on of recurrent pulmonary thromboembol i sm . Earl y ye-nous thrombectomy in the acute si tuation has been advo-cated in an attempt to prevent residual di sabi l i ty despi tethe ini ti al ef f ecti veness of anticoagulants.b0.h1l 19 4j jc #{231} gi jlant therapy continues to be recommended solel y or corn-bined w i th surgery on the theoreti cal grounds of preservingvenous col l ateral f low , #{ 176} thus possibl y avoiding long-termdisability. Fibr inolys is and anti coagulati on therapies thatseem most prom ising are l i kel y to continue to serve as theprimary noninvasive modal i ti es pr ior to surgi cal correcti onof an y ex ist ing ab nor mal it ies.

B l i nded by V i rchow s identi f i cati on that the lower l imbsw ere the major anatom ic source of pulmonary thromboem -bol i sm , technical advances and medical therapies for theprevention of f urther pulmonary thromboembol i sm havelong centered around the inferior vena cava as the majoravenue of subsequent thromboembol i sm . W hen contem-plati ng the use of an inferior vena caval f i l ter, the surgeon/invasi ve radiol ogist must be aw are ofnot only the anomalous

venous return, megacava, but al so the possibi l i ty of pulmo-nary thromboembol ism ori gi nati on i n the upper ex trem i tyveins. I nserti on of an infer ior vena caval f i l ter i n the lattercircumstance w oul d be di sastr ous!

I t is hoped that upper ex trem i ty venography , and perhapsin the near f uture duplex scanning and l i ght ref l ectionrheography,a w i l l be con t em p la t ed w h en eve r p u lm on a r ythromboembolism occurs in the presence of upper ex trem ityvenous access. Superi or vena caval pl acement of venousf i l ters in humans has rarely been perf ormed but may prov idefurther p r o t ec t ion of r e cu r r en t p u lm on a r y embol i sm w henother m odes of therapy are contrai ndi cated.Technkal Info rmation With Regard to SVC F ilte rInsertion

Pr ior to the inserti on of the f i l ter , the distance betw eenthe lef t groin and the SV C should be measured, using aguide w i re clamping technique. I n our case, thi s i ndi catedthat t he i nt ro ducer w as of adequate length. I t should benoted that in our patient, w ho was of average height, thetotal l ength of the introducer had to be inserted in order todel i ver the i f i ter to the desi red locati on. W e thereforesuggest that f or patients greater than 170 cm in height,l onger introducers be used. A potenti al problem w i th thesedev i ces i s that they may preclude the use of thrombol y tictherapy because of f ear of excessive retroperi toneal medi -asti nal bleeding or f rom the inserti on si te should furthermassive pulmonary thromboembol i sm occur. The recentdevelopment of temporary and vena caval f i l ters may negatethe latter f ears.

C ONC LU S I ON SA recent prospecti v e tr i al concluded that pulmonary

embol i sm is not a rare compl i cati on in upper ex trem i tyD V T , and catheter-related V Fseems to be at the greatestr isk.2 U pper ex trem i ty D V T must now be taken seriously asa harbinger of possible pulmonary thromboembol i sm . A si l l ustrated in our case, a combination of ri sk f actors, ie ,hypercoagulabi l i ty secondary to recurrent pulmonary car-c inoma, and the cannulati on of the central v eins madeembolizat ion f rom an upper extremity DV T possible. W iththe system ic and pulmonary venous systems being accessedin cr ea sin g ly for a m u lt it u d e o f in va siv e d ia g n o st ic a n dtherapeuti c procedures, upper ex trem i ty venography andpossibl y newer less i nvasiv e modal i t i es should be contem -plated w henever pulmonary thromboembol i sm occurs inthe presence of upper ex trem i ty venous access. The inserti onof an SV C if i ter m ay prov ide further protecti on againstrecurrent nulmonarv embol i sm when other modes of theranva re con t ra rn di c ated .

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3 H a r l e y DP , W hi te B A , N elson R J , Mehr inger C M . Pulmonaryembolism secondary to venous thrombosis of the arm . A m JSurg 1984; 147:221-24

4 M onreal M , R ey-J o ly C , R u iz J, Sal vador R , L afoz E, V iv er E.


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1890 D iagnosis of P c ar i ni l I nfection by I dentif ication of P c ar i n! ! fr i Pleural Fluid ( Sch aumbe r g et a! )

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12 K ak k er V V H ow e C I , N icolaid es A N , Benney JT C , C lar k e M B .Deep vein th r om bosis of t h e leg: i s t her e a h igh r isk gr oup?Am J Surg 1 97 0; 1 20 :5 27 -3 0

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D ia g n o s is o f P n e um o c y s tis c a rin iiIn fe c t io n in HIV -S e ro p o s it iv eP atients by Identification ofp car ini i i n P le u ra l Flu ld *Thoina ,s H . Sch aumbe r g , M.D . ; Lynn M. Schna pp , M.D . ;Kenneth G . Ta ylor , M.D . ; andJe ffrey A. G olde n, M .D ., F C.C.P

Pneumocystis c a r in l i pneumon ia (PCP) is the most commonpulmonary complication ofA IDS and is typically diagnosedby the identification of P car i n l i organisms in sputum,bronchoalveolar lavage fluid, or tissue obtained with trans-bronchial biopsy. We descri be tw o H 1V - seroposi ti ve patientswith pleural effusions in whom the diagnosis of P ca r i n l iinfection was made by examination ofpleural f luid. Pleuraleffusions associated with PCP are very unusual but canprovide a source ofthagnostic material particularly in thosem y patients who have development of a spontaneouspneumotho r ax and require chest t ube i nser ti on.

(C hest 1 993 ; 103 : 1890-91 )

AFBacid-fast bacteria; CM Vcytomegalovirus; H 1V h1man immunodeficiency virus; L DH lactate dehydrogenase;MAC= M ycobacterium avium com p l ex ; PC P Pneumocyatisc a r i n i l pneumon ia

P n e u nw c y s t L I ca r i n i i pneumonia (PCP) occurs in 80percent of all patients w ith acquired immunodeficiency

syndrome (A IDS) at some time during the course of theirillness. A lthough spontaneous pneumothorax is a well-described complication of PCP, actual involvement of thepleural space causing inflammation and a signif icant ef fusioni s ver y uncom m on. I n fact, i t has been stat ed that ifa pleuraleffusion is present, it is probably indicative of a disorderother than PC? In this article, we describe two patients inwhom the diagnosis of P ca r i n i i infection was made byevaluation of pleural fluid. To our knowledge, identif icationofPca rin i i in pleural fluid has not been described previously.

CASE 1CASE REPORTS

A 23-year-old m an w i th hem oph i l ia A w as exam ined b ecause of 2weeks of a nonp r od uct i v e cou gh , dy sp nea on exer t i on , f ever s, an d

* F r om the Pu lm onar y D i v i sion U n i ver si t y of C al i f or n i a at SanFranc isco.


7/30/2019 Chest-1993-Black-1887-90

6/6

DOI 10.1378/chest.103.6.18871993;103; 1887-1890Chest

M D Black, G J French, P Rasuli and A C Bouchardlethal.

Upper extremity deep venous thrombosis. Underdiagnosed and potentially

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