The Clot That Spoke Too Late: Chronic Pulmonary Thromboembolism Revealing Hidden Gastric Carcinoma

Abstract

Pulmonary thromboembolism is caused by obstruction of the pulmonary arterial circulation by thrombi, most often originating from deep veins of the lower limbs. Malignancy is a well-known risk factor for thromboembolism because it creates a procoagulant state. In this case, we report a 57-year-old male who presented with breathlessness, chest pain, and bilateral lower limb swelling. He had a prior history of pulmonary thromboembolism with no identifiable provoking factors and negative thrombophilia workup, including normal homocysteine levels. Clinical examination showed tachycardia, elevated jugular venous pressure, and signs suggestive of right heart failure. Laboratory investigations revealed severe anemia with iron deficiency and positive stool occult blood. Imaging showed chronic pulmonary thromboembolic disease with pulmonary hypertension and right ventricular dysfunction. Further evaluation with abdominal imaging and endoscopy identified a gastric lesion, and biopsy confirmed moderately differentiated gastric adenocarcinoma with liver metastasis. The patient was managed with supportive care, anticoagulation, and chemotherapy. This case shows that unprovoked pulmonary thromboembolism can be an early presentation of an underlying malignancy and highlights the importance of systematic evaluation in such patients.