A Case of Carbon Monoxide Poisoning with Thrombus in Right Atrium
A 24-year-old female patient with no preexisting disease was brought to the emergency unit for altered mentality due to suicidal exposure to CO. The duration of the exposure was unclear. She showed a good general appearance, the level of consciousness was alert: Glasgow Coma Scale was measuring up to 15. Vital signs were blood pressure of 132/101 mmHg, pulse rate of 87/min, respiration rate of 20/min and body temperature of 35.4℃. Oxygen saturation measured using pulse oxymetry was 100% when 15 L/min oxygen was applied through a reservoir bag mask. She was 164 cm tall and weighed 50 kg, and her body mass index was 18.6 kg/m2. Lower and upper limb arterial and venous examination revealed normal circulation. In detailed system examinations, no pathological neurologic signs were detected.\nThe chest radiography showed mild cardiomegaly with pulmonary edema in both lung fields. Laboratory analyses revealed the following: white blood cells, 21200/µL; blood urea nitrogen, 17 mg/dL; creatinine, 0.75 mg/dL, and blood glucose, 101 mg/dL, D-dimer 0.28 ug/mL. Cardiac enzymes were elevated (CK: 3306 U/L, CK-MB: 90.6 ng/mL, troponin I: 1.899 ng/mL, lactate dehydrogenase: 334 U/L). Arterial blood gas was performed and revealed pH 7.40, PaCO2 33 mmHg, PaO2 380 mmHg, HCO3 20 mmol/L, and the fraction of carboxyhemoglobin 16.0% (reference range < 2%). QT interval was prolonged in the electrocardiograph (ECG). The patient was transferred to the intensive care unit. At that time, she complained of newly onset chest pain, and cardiology consultation was requested. Pain was mainly retrosternal, lasted for several minutes, with no aggravating or relieving factors, and no change in position or respiration. ECG showed sinus rhythm with T wave inversion in precordial leads. Coronary computed tomography (CT) angiography performed to rule out coronary artery disease revealed normal coronary artery. Transthoracic echocardiography on the same day showed moderately reduced ejection fraction (42%), and akinesia of left ventricular apex. Stress induced cardiomyopathy or ischemic insult of left anterior descending artery were suspected. During comprehensive echocardiographic examination, echogenic mass with multiple nodularity in right atrium (RA) was identified. The size measured about 30 × 15 mm, and it appeared to be attached to the junction of superior vena cava. Transesophageal echocardiography and cardiac magnetic resonance imaging (MRI) were requested for further characterization of the mass. In mid-esophageal 140 degree view, a large nodular mass was attached to appendage of RA. Moreover, the mass was highly mobile and oscillating up and down across the tricuspid valve throughout the cardiac cycle (). The foremost diagnosis to exclude in this patient was intracardiac thrombus, and therefore we started anticoagulation therapy immediately. Cardiac MRI 1 day after anticoagulation therapy showed delayed enhancement suggestive of a thrombus, and an obvious reduction in size of the thrombus to 8 mm (). For the purpose of determining the etiology of thrombosis, she was questioned concerning recent potential precipitating conditions, such as surgery, immobilization and use of medications including oral contraceptives. Furthermore, she was evaluated for genetic and connective tissue disease leading to thrombophilic conditions. There were no identifiable risk factors for hypercoagulable state. Complete lower extremity ultrasound and abdominopelvic CT was conducted for suspicion of peripheral vein thrombosis and it demonstrated no thrombosis in other organs. The follow-up transthoracic echocardiogram was done on sixth day after anticoagulation, and showed no residual thrombus in the RA and normalized left ventricular (LV) systolic function (). The patient was discharged without any complication. The patient has been free of symptoms and there have been no clinical features of neurologic or thromboembolic complications during the 3-months of follow-up.