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PULMONARY VEIN THROMBOSIS ASSOCIATED WITH A LARGE HIATAL HERNIA  
Yu Zhao, Reynold Andika, Richard Alweis
Rochester Regional Health/Unity Hospital, Rochester, NY, United States

Introduction Pulmonary vein thrombosis (PVT) is a rare condition. The limited existent literature consists mainly of case reports, so the incidence rate is unknown. However, it is potentially fatal with the risk of acute systemic arterial embolism, thus merits clinician awareness. We report a case of PVT secondary to compression from a large hiatal hernia. Case Presentation An 82-year-old male was referred to the emergency department after incidental finding of left lower lobe pulmonary vein thrombosis (PVT) on his chest computerized tomography (CT) for his large hiatal hernia follow-up. He was discovered to have an asymptomatic large hiatal hernia 7 years ago and was treated conservatively. However, 17 months prior to admission the patient developed intermittent epigastric pain and dyspnea on exertion (DOE). Chest CT at that time showed a large hiatal hernia compressing his left lung with associated atelectasis, but no vascular abnormalities. Due to his age, he was not considered a surgical candidate for hiatal hernia repair. Although epigastric pain and DOE persisted, extensive work-up, including pulmonary function tests, nuclear cardiac stress test, coronary angiogram, and a barium swallow were all negative, leading to the repeat CT scan of his chest done the day of admission. In the ED, lower extremity Doppler study was negative. Physical exam was notable for abdominal distention but no tenderness. He was treated with Lovenox and has bridged on to therapeutic doses of Coumadin. After several weeks of anticoagulation, his epigastric pain and dyspnea resolved, and he remained free of systemic embolic events. Discussion PVT is a rare condition associated with significant morbidity. Although many patients are asymptomatic, PVT can manifest with nonspecific chest pain, cough, hemoptysis, and dyspnea. Complications include pulmonary edema or infarction, or rarely, systemic embolism, including limb ischemia, stroke, and splenic infarction. Etiologies based on case reports have identified anatomic changes as the main cause, including lobectomy, lung transplant, and compression phenomena from large hiatal hernias or masses. Malignancy and hypercoagulability are potential risk factors. For close monitoring, many clinicians are more comfortable with heparin or low molecular weight heparin bridging to Coumadin. Clinicians should keep PVT in mind due to its nonspecific symptoms but potentially severe complications. References Chaaya, Gerard, and Priya Vishnubhotla. "Pulmonary vein thrombosis: a recent systematic review." Cureus 9.1 (2017).