Kamidani Ryo, Kumada Keisuke, Okada Hideshi, Yoshimura Genki, Kanayama Tomohiro, Tomita Hiroyuki, Miura Tomotaka, Oiwa Hideaki, Mizuno Yosuke, Kitagawa Yuichiro, Yasuda Ryu, Fukuta Tetsuya, Miyake Takahito, Doi Tomoaki, Yoshida Takahiro, Yoshida Shozo, Hara Akira, Ogura Shinji
Advanced Critical Care Center, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.
Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan.
Int J Emerg Med. 2021 Sep 15;14(1):53. doi: 10.1186/s12245-021-00377-2.
Pulmonary tumor thrombotic microangiopathy (PTTM) is a condition that involves the development of pulmonary hypertension due to the presence of microscopic tumor emboli of the peripheral pulmonary arteries. Here, we report a case of rapidly exacerbating PTTM associated with gastric cancer that was identified postmortem through pathological autopsy.
A 52-year-old Asian woman who experienced anterior chest pain while coughing visited the orthopedic department of the Gifu University Hospital. She was diagnosed as having multiple osteolytic bone metastases throughout her body and was subsequently scheduled to undergo combined positron emission tomography and computed tomography (CT) to search for a primary lesion. However, 4 days after her visit to the orthopedic department, she was unable to stand up and thus visited the emergency department. At the time of admission, physical examination results revealed that she had a percutaneous oxygen saturation level of 90% (on room air) and cyanosis and that she was in a state of hemodynamic shock. Laboratory test results revealed elevated levels of fibrin degradation products and D-dimer in her blood. Chest CT results were normal. She was admitted to the hospital's general ward for follow-up but soon entered a gradually worsening state of shock and respiratory failure. Electrocardiography revealed findings associated with right heart strain; however, contrast-enhanced CT did not reveal the presence of pulmonary embolism. She was admitted to the intensive care unit and was treated for pulmonary hypertension; however, 45 h after her arrival at the hospital, she died of respiratory failure. A pathological autopsy revealed the presence of gastric cancer, tumor microemboli, and fibrous intimal thickening of the peripheral arteries of both lungs; thus, a diagnosis of PTTM was made.
In patients with carcinoma of unknown primary site and pulmonary hypertension with pulmonary embolism ruled out by CT, emergency physicians and intensivists must consider the possibility of PTTM, which represents an oncologic emergency, and initiate chemotherapy administration as soon as possible.
肺肿瘤血栓性微血管病（PTTM）是一种由于外周肺动脉存在微小肿瘤栓子而导致肺动脉高压的疾病。在此，我们报告一例与胃癌相关的迅速加重的PTTM病例，该病例通过病理尸检在死后得以确诊。
一名52岁的亚洲女性在咳嗽时出现前胸疼痛，前往岐阜大学医院骨科就诊。她被诊断为全身多发溶骨性骨转移，随后计划接受正电子发射断层扫描和计算机断层扫描（CT）联合检查以寻找原发灶。然而，在她前往骨科就诊4天后，她无法站立，因此前往急诊科。入院时，体格检查结果显示她的经皮血氧饱和度为90%（在室内空气中），伴有发绀，且处于血流动力学休克状态。实验室检查结果显示她血液中的纤维蛋白降解产物和D - 二聚体水平升高。胸部CT结果正常。她被收治入院普通病房进行随访，但很快进入休克和呼吸衰竭逐渐加重的状态。心电图显示与右心劳损相关的表现；然而，增强CT未显示肺栓塞的存在。她被收入重症监护病房并接受肺动脉高压治疗；然而，在她入院45小时后，死于呼吸衰竭。病理尸检显示存在胃癌、肿瘤微栓子以及双肺外周动脉纤维内膜增厚；因此，做出了PTTM的诊断。
对于原发部位不明的癌症且CT排除肺栓塞的肺动脉高压患者，急诊医生和重症监护医生必须考虑PTTM的可能性，PTTM是一种肿瘤急症，应尽快开始化疗。
