Hypercoagulability As A Paraneoplastic Manifestation Of Suspected Primary Lung Malignancy: A Case Report

Abstract

Background
Trousseau syndrome is a paraneoplastic hypercoagulable state most often associated with mucin producing adenocarcinomas. Lung adenocarcinoma commonly presents with venous thromboembolism, but multifocal arterial thrombosis as the initial manifestation is rare and diagnostically challenging. Recognition of occult malignancy is essential when unexplained, recurrent, or multi-territorial thrombosis occurs in older adults.
Case Report
A 62-year-old non-smoking woman presented with acute breathlessness, altered sensorium, and severe subacute pain involving the left upper and lower limbs. General examination showed presence of cyanosis of the left-sided nail beds, cold peripheries. In addition, there were absent peripheral pulses and absent Doppler signals on left side. These findings suggested acute limb ischemia. Examination of respiratory system showed reduced right basal air entry with dullness to percussion. Additionally, there was progressive leukocytosis, neutrophilia, hypoalbuminemia, and progressive coagulopathy on serial testing. Hypokalaemia was also present. Pleural fluid was lymphocyte-predominant, exudative, and cytology-negative for malignant cells. CT aortogram demonstrated complete thrombosis of the left axillary and left iliac arteries, splenic thrombosis, bilateral peripheral vascular compromise, and
involvement of the abdominal aorta and mesenteric vessels. CT brain showed left temporal ischemic changes suggestive of embolic phenomena. High-resolution CT thorax revealed a heterogeneously enhancing right lower lobe mass with satellite nodules and right-sided pleural effusion, radiologically favouring primary lung adenocarcinoma. A diagnosis of suspected right lung adenocarcinoma with paraneoplastic hypercoagulability causing multifocal arterial thrombosis was made. Histopathological confirmation could not be obtained during the hospital stay. The patient was managed in intensive care with unfractionated heparin followed by subcutaneous heparin, dual antiplatelet therapy, statin therapy, supportive care, and monitoring. Surgical vascular intervention was considered unfeasible because of extensive thrombotic disease.
Conclusion
Multifocal arterial thrombosis may be the first manifestation of occult lung adenocarcinoma. Clinicians should evaluate for malignancy in unexplained arterial thromboembolism, particularly when vascular involvement is extensive and conventional risk factors are insufficient.