SHM Converge Scientific Abstract ePoster Gallery-A Case of Pulmonary Tumor Thrombotic Microangiopathy (Pttm) From Incidental Finding of Poorly Differentiated Esophageal Adenocarcinoma

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This case describes a 71-year-old man who developed acute hypoxemic respiratory failure and hypotension during a scheduled TEE/cardioversion. After transfer to the ICU, he had bleeding from a nasogastric tube, and endoscopy revealed a distal esophageal mass. Biopsy confirmed poorly differentiated signet ring esophageal adenocarcinoma.<br /><br />His evaluation showed signs of severe pulmonary hypertension and right heart strain/failure, including markedly elevated pulmonary artery pressures on echocardiogram and severe right ventricular enlargement. CTA chest was negative for pulmonary embolism, but imaging later showed worsening diffuse ground-glass and “tree-in-bud” changes, with a V/Q scan suggesting a mild “moth-eaten” pattern. In the setting of newly diagnosed gastrointestinal adenocarcinoma, negative infectious workup, progressive hypoxemia, and pulmonary hypertension, the team suspected pulmonary tumor thrombotic microangiopathy (PTTM).<br /><br />PTTM is a rare, often fatal complication of malignancy in which tumor emboli lodge in the pulmonary microvasculature, triggering thrombosis and vascular remodeling that leads to rapid pulmonary hypertension and respiratory failure. It is most commonly associated with adenocarcinomas, especially gastric cancers, but can occur with esophageal adenocarcinoma as well. Diagnosis is difficult and is frequently made postmortem.<br /><br />The patient was trialed on treprostinil for pulmonary hypertension, but his respiratory status continued to worsen. Because of his poor prognosis, declining condition, and limited treatment options, Palliative Care was consulted. He chose hospice and comfort-focused care.<br /><br />The report emphasizes that PTTM should be considered in cancer patients with unexplained, rapidly progressive dyspnea and pulmonary hypertension, particularly when imaging and workup do not support infection or thromboembolism.

Asset Subtitle

Dileep K. Mandali

Meta Tag

Author List Bella Gonzalez Perez, Dileep K. Mandali

Category Clinical Vignettes

Concept Pulmonary Tumor Thrombotic Microangiopathy

Concept Pulmonary Hypertension

Concept Dyspnea

Concept Malignancy

Concept Adenocarcinoma

Distinguished Non-Finalist

Presenter Organization Tulane University School of Medicine

Presenting Author Dileep K. Mandali

Track Adult

Keywords

pulmonary tumor thrombotic microangiopathy

PTTM

esophageal adenocarcinoma

pulmonary hypertension

acute hypoxemic respiratory failure

right heart strain

tumor emboli

ground-glass opacities

tree-in-bud changes

palliative care

Pulmonary Tumor Thrombotic Microangiopathy

Pulmonary Hypertension

Dyspnea

Malignancy

Adenocarcinoma