Abstract

To the Editor:

A 34-year-old African-American woman presented to the emergency department complaining of 6 hours of bilateral pleuritic chest pain and shortness of breath. She had experienced four similar though less severe attacks during the previous 6 weeks. She had also noted a weight loss of 15 pounds during the previous 6 months. Her history was significant for a 40-pack-year smoking history as well as nine uneventful, full-term pregnancies. Physical examination revealed an anxious-appearing woman who was mildly short of breath at rest. Her blood pressure was 105/83 mm Hg with a pulse rate of 125 beats/min. Respiratory rate was 26 breaths/min with 96% oxygen saturation on 4 L/min oxygen. Neck veins were swollen bilaterally, with mild facial edema while upright. Breath sounds were diminished at both bases. Her electrocardiogram showed sinus tachycardia with a normal axis and nonspecific ST-T-wave changes. Electrolyte levels and results of renal function tests were normal, as were results of liver and coagulation tests. Chest radiograph film showed a 6-cm right paratracheal mass with small, bilateral pleural effusions. Spiral computed tomography of the chest revealed a thrombus obstructing the superior vena cava and extending superiorly to the right internal jugular vein and inferiorly into the right atrium. Thrombi were seen in both pulmonary arteries, and the 6-cm right mediastinal mass was worrisome for malignancy.