Abstract
Pancreatic cancer represents one of the most prothrombotic neoplasms secondary to high tumoral expression of tissue factor, cytokine release, activation of leukocytes and hypofibrinolysis. Studies have shown that the incidence of thrombotic complications can reach up to 36%.
We present a case of an 84-year-old male patient who was admitted onto the Geriatrics ward with a 3-day history of sudden-onset dyspnoea, productive cough, pallor, and general malaise. Admission blood revealed microcytic anaemia (Hb 91 g/L), neutrophilic leukocytosis (WCC 29.9 x 10^9/L, Neut 26.9 x10^9/L) and elevated C-reactive protein (211 mg/L). Despite high clinical suspicion of pneumonia, chest X-ray did not demonstrate any pathology.
On day 2 of admission, D-dimer was requested, and the critical result of 3500 ng/mL was noted. Patient was immediately commenced on anticoagulation therapy and urgent CT-PA demonstrated the presence of a pulmonary embolus in a posterior sub-segmental artery of the right lower lobe.
On day 3, patient manifested left-sided lower limb weakness along with reduced sensation to light touch up to the left knee. Patient did not demonstrate cortical symptoms. Urgent CT-Head revealed hypodensity in the right parietal region suggestive of acute ischaemic infarction.
On day 5, patient reported pain and swelling of the left calf. Physical examination rendered high suspicion of left deep vein thrombosis with calf circumferential difference of 4cm (Left 34cm, Right 30cm) and significant tenderness on palpation. In light of three consecutive thromboembolic events within 5-day course of admission, suspicion of cancer-associated thrombosis was established. Urgent CT-AP was conducted, 5cm carcinoma at the tail of the pancreas with extensive hepatic, splenic and adrenal metastatic disease. The following case warrants attention from the clinicians as unprovoked pulmonary embolism should prompt investigation for potential underlying malignancy.
Furthermore, it highlights the malignancy-induced hypercoagulability and risk of cancer-associated thrombosis, particularly in the context of pancreatic carcinoma.