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.