Images in Emergency Medicine
Article Outline
A 56-year-old woman came to the emergency department after 1 day of nausea, vomiting, fever, and chills. A few hours before, she developed the sensation that “her head was swelling.” She developed respiratory distress and required intubation. The patient has a history of idiopathic gastroparesis and has had multiple surgical procedures, including placement of a gastric pacemaker and multiple central venous catheters. She had a tunneled central venous catheter placed for blood withdrawal more than 1 year ago. Physical examination demonstrated nonpitting edema and bluish discoloration from the face to the clavicles (Figure 1, Figure 2). Her tongue and oral mucosa were also edematous. Venous duplex of the neck and upper extremities, computed tomography (CT) angiogram of the chest, and transesophageal echocardiogram results were all negative.
Figure 1.
Patient after intubation.
Figure 2.
Patient after intubation.
Diagnosis
Superior vena cava syndrome
The diagnosis was suspected according to the patient’s physical examination but was proven with venography. A venous duplex test failed to reveal any thrombosis. A CT angiogram of the chest did not show a mass that could cause superior vena cava compression, nor did it demonstrate thrombosis. A transesophageal echocardiogram was obtained to rule out tamponade.
Superior vena cava syndrome is usually associated with external compression from intrathoracic masses, most commonly lung cancers.1 Venous thrombosis associated with central venous catheters is increasingly being recognized as a cause of superior vena cava syndrome.2, 3 Our patient had a central venous catheter, and dehydration from gastroenteritis likely contributed to her acute presentation. Venography demonstrated superior vena cava stenosis and thrombosis (Figure 3). Thrombolytic therapy and angioplasty were required to relieve the obstruction (Figure 4). Within 4 days of treatment, her physical examination returned to normal (Figure 5).
Figure 3.
Venogram of superior vena cava, demonstrating stenotic and thrombosed proximal segment.
Figure 4.
Venogram of superior vena cava after successful thrombolysis and angioplasty, showing improved proximal flow.
Figure 5.
Patient 4 days after presentation and just before discharge. Used with permission of Barry Mitchell, MD, Department of Internal Medicine, West Virginia University School of Medicine, Charleston Division, Charleston, WV.
References
- . The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore). 2006;85:37–42
- . Treatment of superior vena cava thrombosis with recombinant tissue type plasminogen activator. Chest. 1991;99:1298–1301
- . Successful treatment of prolonged superior vena cava syndrome with thrombolytic therapy: a case report. J Vasc Surg. 1994;20:108–113
For the diagnosis and teaching points, see page 516.To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com
PII: S0196-0644(07)00378-2
doi:10.1016/j.annemergmed.2007.03.017
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
