Shikha Kapil, MD
Assistant Professor/Attending Physician
MedStar Washington Hospital Center/Georgetown University SOM
Washington, District of Columbia, United States
Disclosure information not submitted.
Title: Acute Thrombotic SVC Syndrome Causing Airway Compromise in Presumed Anaphylaxis
Introduction: Superior Vena Cava (SVC) syndrome is caused by intrinsic or extrinsic central thoracic vein obstruction causing face, neck, arm swelling, dyspnea and in severe cases airway edema and compromise. Classically, this is associated with malignancy. We present a case of acute thrombotic obstruction of multiple central thoracic veins leading to SVC syndrome causing significant airway compromise masquerading as anaphylaxis.
Description: A 36-year-old female with a history of lupus nephritis on hemodialysis, ACE-inhibitor associated angioedema, previous DVTs presented with acute onset dyspnea with swelling of her tongue, lips, throat and neck. She was treated initially for acute anaphylaxis with IM epinephrine, famotidine, diphenhydramine, and dexamethasone. CT neck revealed supraglottic and retropharyngeal edema with moderate airway narrowing. Laryngoscopy revealed symmetric tongue fullness, significant muscle tension dysphonia, epiglottic and arytenoid edema with cobblestoning. An epinephrine drip was initiated as her symptoms persisted despite 3 doses of epinephrine. In the Medical ICU, she became profoundly dyspneic, with no audible air entry bilaterally and intubated in anticipation of a critical airway. Due to treatment refractory symptoms, other etiologies for this deterioration were sought for. A bedside venous doppler showed acute obstruction in the left brachiocephalic and axillary veins, chronic obstruction in the right internal jugular with abnormal doppler signals bilaterally indicating more proximal obstruction. Repeat CT neck with contrast revealed a near complete occlusion of right and left brachiocephalic veins, right internal jugular vein, left subclavian veins. Heparin drip was initiated, and she underwent a mechanical venoplasty.
Discussion: SVC syndrome is most often encountered with chronic to subacute symptoms in patients with malignancy. Thrombotic cases, such as in our patient, are becoming increasingly more frequent due to the rise of central venous access for dialysis or implanted devices such as pacemakers. The acute nature of a thrombotic SVC can produce similar symptoms to anaphylaxis. This case further highlights the importance of frequently evaluating a patient's response to treatment and consideration of alternative diagnoses.