Incidental detection of spontaneous floating internal jugular vein thrombosis with acute pulmonary embolism.

Sir,

Internal jugular vein thrombosis (IJVT) is a rare but potentially fatal condition.[1] It is usually caused by catheterization history of central venous catheter (CVC), malignancy, thrombophilia, or local infection.[234] Spontaneous IJVT occurs when there are no apparent predisposing causes. IJVT without CVC may be the first manifestation of an occult malignancy and it must be ruled.[5] We report here a rare case of idiopathic IJVT complicated with pulmonary embolism (PE).

A 75-year-old male was admitted to the Intensive Care Unit (ICU) for acute exacerbation of chronic obstructive pulmonary disease requiring endotracheal intubation and mechanical ventilation. On admission, we incidentally detected floating thrombosis in the right IJV [Figure 1a], with spontaneous echo contrast [Figure 1b] during the ultrasound-guided IJV cannulation [Video 1].

Figure 1

(a) Long-axis view: Floating thrombosis of the right internal jugular vein. (b) Short-axis view: Spontaneous echo contrast in the right internal jugular vein. (c) Transthoracic echocardiography four cavity view: Right ventricle dilation and paradoxical interventricular septal motion

Transthoracic echocardiography showed severe dilatation of the right chambers, paradoxical wall motion septum [Figure 1c], with pulmonary hypertension of 80 mmHg.

A chest computed tomography confirmed acute bilateral PE involving segmental pulmonary arteries. The patient was treated with intravenous unfractionated heparin. This patient had no malignancy, coagulation disorder, or infection.

This case highlights the value of bedside ultrasound in the ICU setting. Early diagnosis and appropriate management are important to prevent potentially fatal complications from this condition. The patient needs to be investigated thoroughly to rule out a pathological cause of IJV thrombosis, especially deep neck infections, coagulation disorders, and local or distant malignancies.

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