A 46-year-old male was admitted to the Department of Respiratory and Critical Care Medicine of the First Affiliated Hospital of Zhengzhou University on July 1, 2024 due to "intermittent massive hemoptysis for 4 days". Previous history of hypertension, no medical treatment. Physical examination reduced breathing sounds in the right lower lung. After admission, hemostatic treatment was given with phenolsulfamide 1 g/d and tranexamic acid 0.5 g/d. An electrocardiogram performed on the first day of admission showed atrial fibrillation. On the second day of admission, CT angiography of the pulmonary artery (Figures A and B) showed no signs of embolism. There was a large patch of low-density filling defect on the right side of the left atrium, about 5.6 cm ×6.4 cm in size (Figure C). There was no enhancement of the right upper and lower pulmonary veins, which were connected to the filling defect of the left atrium. The right hilar shadow was enlarged, the right lung had multiple interlobular septal thickening, bilateral pleural effusion, and the right side was marked by multiple slightly larger lymph nodes in the mediastinum, slightly larger heart shadow, and a small amount of pericardial effusion. No tumor cells were found in the pathological findings of pleural effusion. Hemoptysis was relieved after bronchial artery embolization on the third day of admission because hemoptysis was still intermittent after 2 days of hemostatic treatment, and the volume of hemoptysis was about 100 ml each time. In order to exclude atrial tumors, PET-CT examination on the 6th day of admission revealed inflammatory lesions in the right hilar and soft tissue masses in the left and right atrium in the pericardium (CT value 40 Hu). A cardiac ultrasound examination on the 11th day of admission showed that the right pulmonary vein thrombosis extended into the left atrium (Figure D, arrow). On the 13th day of admission, bronchoscopy showed protuberance of the mucosa in the anterior segment of the right upper lobe and the dorsal segment of the right lower lobe. Biopsy pathology showed chronic inflammation of the bronchial mucosa with epithelial squamation, subepithelial congestion and hemorrhage of the mucosa with organization. Combined with the imaging characteristics, considering pulmonary vein sarcoma or pulmonary vein thrombosis, he was transferred to the cardiac surgery department and performed "pulmonary vein foreign body removal + left atrial thrombosis removal" on the 25th day of admission. Postoperative pathology showed pulmonary vein thrombosis with partial organization. Pulmonary venous thrombosis (PVT) was confirmed. PVT is a rare thromboembolic disease. Pulmonary surgery, atrial fibrillation and tumors are common causes, and the clinical manifestations are not specific. Massive hemoptysis caused by PVT is very rare, and its mechanism may be related to the obstruction of local venous return caused by pulmonary venous thrombosis, increased pulmonary capillary pressure and rupture.
