Case presentation
A 44 year-old policeman was admitted in the emergency room of the
Hospital Center of Montlucon for pre-syncope with mild dyspnea, without
chest pain. Past-history revealed that the patient was followed in
psychiatry for mental depression since 5 months and treated by paroxetin
20mg daily. He also was diagnosed of pulmonary embolism at the age of 13
several days after a knee trauma. He had no recent history of trauma,
surgery or immobilization. Upon arrival, the patient had a satisfactory
general and hemodynamic state, he was eupneic with a clear
cardiovascular examination. 12-Limbs electrocardiogram was normal with
regular sinus rhythm at 66 bpm, transthoracic echocardiography showed
non dilated cavities with normal bi-ventricular systolic functions and
normal pulmonary pressure. A CT-Pulmonary Angiography found a bilateral
segmental and subsegmental pulmonary embolism without any signs of
gravity (Figure 1). Biological workups found a normal full blood count,
Troponin T level at 13 pg/ml (normal range<14 pg/ml) NT pro
NBP at 14 pg/ml (normal
range<125 pg/ml). We concluded to a recurrent pulmonary
embolism in a young man. He was therefore hospitalized for investigation
of the etiology and we started anticoagulation with Apixaban 10 mg twice
daily. During hospitalisation in the cardiology unit, the patient
presented typical frontal release signs with deshinibition, euphorism,
grasping and sucking. The Cerebral CT-Scan found a large heterogenous
hypervascularized multi-lobular tumor with a large peripheric oedema
located in the frontal region associated with sub-falcorial herniation
suggesting high grade Glioblastoma (Figure 2). Work-up for thrombophilia
(antithrombin III, protein C, protein S, Factor V mutation,
anticardiolipin, anti-Beta2-GP1), tumoral biomarkers (CA 19-9, CEA, AFP,
Cyfra 21-1, NSE, PSA), HIV serology, abdominal and pelvic scan were
unremarkable. We started treatment with Methylprednisolone 120 mg
intravenously and the patient was transferred to the neurosurgical team
for better management.