Trousseau syndrome: gallbladder carcinoma presenting with bilteral lower limbs' migratory deep vein thrombosis (DVT) and superficial thrombophlebitis

Case contributed by Dr Mohammad A. ElBeialy

Presentation

Right leg pain and swelling since 2 days followed by dyspnea, chest pain and fever. The patient gave a history of chronic DVT of the left lower limb.

Patient Data

Age: 72 years
Gender: Female

Extensive acute deep vein thrombosis extending from the right common femoral vein up to the right posterior tibial vein at the level of the medial malleolus. The long saphenous vein is thrombosed as well. Subcutaneous oedema of the entire right lower limb is noted.

Subacute to chronic extensive DVT of the left lower limb veins with superficail thrombophlebitis of the left great saphenous vein. 

MSCT angiography of the pulmonary artery shows:

Multiple non-enhancing filling defects are noted within the distal right main pulmonary as well as the superior and inferior branches down to their 1st, 2nd and 3rd order branches; consistent with acute pulmonary thrombo-embolism.

The main pulmonary artery is patent (yet dilated and is about 3.8 cm at its maximum diameter) as well as patent and homogeneously opacified left main pulmonary artery and its order branches. Mild cardiomegaly with concentric hypertrophy of the left ventricle. Mild atherosclerotic changes of the left anterior descending artery is noted. No pleural or pericardial sac collection.Incidentally noted is enlarged left thyroid lobe with an about 5 X 3 cm iso-dense lesion showing retro-sternal extension abutting the superior mediastinal vessels and mildly deviating the trachea to the right side. Small volume mediastinal lymphadenopathy. Bovine aortic arch with the left CCA arises in common origin with the brachiocephalic artery. The left vertebral artery arises from the aortic arch directly as well.  

The scanned upper abdomen shows fatty hepatomegaly as well as mild splenomegaly and minimal peri-hepatic ascites.

Biphasic MSCT of the lower extremities (arterial and venous phases):

Irregular gall bladder wall thickening with an enhancing gall bladder fundal mass lesion is seen that measures about 3.5 X 2.5 cm in its maximal diameters with ill-definition and infiltration of the gall bladder fossa as well as thickening of omentum with heterogeneously enhancing omental soft tissue sheets abutting the anterior abdominal wall (omental cake/ deposits)  and small amount of ascites consistent with gallbladder carcinoma with peritoneal carcinomatosis.

Extensive thrombosis of the right lower limb veins from the right popliteal vein till the right external iliac vein. All veins are occluded by a soft tissue thrombus and shows mild ring wall enhancement. Severe subcutaneous soft tissue edema are noted around the whole right lower limb as well as subcutaneous fluid collection at the right side of the anterior abdominal wall.

The left external iliac vein, CFV and SFV are slightly reduced in caliber and show partial opacification of the contrast, however, with multiple discrete segments of filling defects representing chronic thrombosis.

Multiple soft and calcific atheromatous plaques are noted along the abdominal aorta, however, no evidence of occlusion or significant stenosis. Normal perfusion of arterial system to both lower limbs with no evidence of compartment syndrome or signs of arterial insufficiency.Patent common femoral and profunda femoris arteries as well as the superficial femoral arteries with no significant lesions. Patent tibio-peroneal trunk as well as the infra-popliteal artereies with fair caliber.

Noted also was bilateral severe knee osteoarthritis with moderate right knee joint effusion.

Case Discussion

Migratory DVT and bilateral superficial thrombophlebitis of the left then right lower limbs was the early signs of a yet to be diagnosed gall bladder carcinoma with peritoneal carcinomatosis.

Trousseau syndrome is a cancer-induced hypercoagulable status with usually undiagnosed or yet to be diagnosed cancer that can present with migratory deep venous thrombosis and thrombophlebitis, acute cerebral infarction, or non-bacterial thrombotic endocarditis.

It must be suspected in elderly patients developing DVT or superficial thrombophlebitis with no definite underlying or predisposing factors. Transient and migratory DVT or superficial thrombophlebitis should prompt the work-up for underlying undiagnosed malignancy in these patients.

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Case Information

rID: 45830
Case created: 9th Jun 2016
Last edited: 1st Nov 2016
Inclusion in quiz mode: Included

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