A 56 year old male without a past smoking history presented to the emergency department with upper respiratory symptoms, fevers, night sweats, urinary retention, and leg weakness. On admission, chest computed tomography (CT) with contrast demonstrated a right perihilar mass with mediastinal extension, prominent mediastinal and paraesophageal lymphadenopathy, and was negative for PE (Fig. 1). Based on focal neurologic findings, magnetic resonance imaging of the head/spine was performed and showed lesions consistent with metastatic disease. Because the clinical-radiographic diagnosis suggested metastatic carcinoma, bronchoscopy with EBUS-guided TBNA of the invasive mediastinal mass was performed. EBUS imaging from the right main stem bronchus demonstrated a mobile filling defect within the right pulmonary artery (Fig. 2) which was confirmed by Doppler (Fig. 3). These characteristics were consistent with a PE. A repeat chest CT with contrast confirmed an acute PE involving the right main pulmonary artery and bilateral segmental pulmonary arteries (Fig. 4). The patient was treated with the preferred anticoagulation in the setting of malignancy; subcutaneous low molecular weight heparin. Pathology from the TBNA biopsy was positive for primary lung adenocarcinoma and the patient was initiated on systemic chemotherapy. Follow-up CT angiogram 3-months later showed resolution of the PE and tumor response to chemotherapy.
Computed tomography of the chest without a pulmonary embolus obtained prior to the EBUS.