Squamous cell carcinoma lung: Presented with bilateral lower limb deep venous thrombosis with gangrene formation
A 41-year-old non diabetic non hypertensive non smoker woman was brought to our department with complain of dry cough, progressive shortness of breath for 2 weeks along with pain and swelling of both feet for 1 week. On examination there was bilateral pitting pedal oedema and raised body temperature of 101°F. Blackening of skin of all the toes on both feet with decreased local temperature and tenderness were revealed on local examination of feet. [] Multiple nodules over scalp were seen as incidental finding. For evaluation of respiratory symptoms, chest X-ray and CT scan thorax were done and revealed left sided massive pleural effusion with atelectasis of left lung.[] Pleural fluid study came as lymphocytic, exudative, ADA level 14 IU/ml with presence of malignant cell. Closed pleural biopsy and report suggested as metastatic squamous cell carcinoma. FNAC from scalp nodule was also positive for metastatic squamous cell carcinoma []. On fiber optic bronchoscopy, there was an infiltrating growth in left upper lobe bronchus and biopsy suggestive of squamous cell carcinoma []. USG doppler of venous system of both lower limbs revealed an organized thrombus in common iliac veins extending into superficial femoral vein with complete occlusion of venous system distal to it. Doppler angiography showed patency of bilateral arterial system like common iliac, internal iliac, external iliac, femoral, popliteal, anterior tibial, posterior tibial, and arteria dorsalis pedis and any arterial occlusion as a cause of gangrene had been ruled out. However, a coagulation profile did reveal the existence of hypercoagulable state with prothrombin time 14.4 s (control 12.5 s), partial thromboplastin time 43.5 s (control 32.2 s), International Normalized Ratio (INR) 1.16, D-dimer raised to 1030 μg/L and a fibrin degradation product 286 μg/ml (normal < 10 μg.ml). Serum for antinuclear antibody (ANA), Ig M and Ig G anticardiolipin antibodies, protein C and protein S was within normal limits. Patient was put on low molecular weight heparin (LMWH) enoxaparin sodium injection subcutaneously at a dose of 40 IU twice daily. After 5 days of treatment with LMWH, INR was repeated and found to be 2.5. Patient was shifted to oral warfarin 5 mg daily from LMWH after 7 days of treatment. She was diagnosed as a case of stage IV squamous cell carcinoma lung and treated with palliative chemotherapy regimen consisting of carboplatin and gemcitabine. After 1st cycle of chemotherapy patient was discharged in stable condition with oral warfarin at a dose of 5 mg daily and asked to check INR regularly.