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\begin{document}

\title{Always track the etiology of thromboembolism in younger adults : brain
tumor revealed by recurrent pulmonary embolism in a young man}



\author[1]{Mazou Temgoua}%
\author[2]{Alfousseyni Keita}%
\author[2]{Mekidian Diallo}%
\author[3]{Alice Ossa}%
\author[2]{Kieu Nguyen}%
\author[2]{hilic Enver}%
\author[2]{Nouhoun Diallo}%
\author[2]{Gislain Endamena}%
\author[2]{Sami Assi}%
\author[2]{Lise Camus}%
\author[2]{Sylvain Chanseaume}%
\affil[1]{University of Yaounde I}%
\affil[2]{Hospital Centre Montlucon}%
\affil[3]{Universite de Yaounde I}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Pulmonary embolism is a major cause of death worldwide. Recurrences are
mainly observed in patients with coagulation disorders or cancers. We
describe the case of a brain tumor (Glioblastoma) revealed by behavioral
disorder in a young patient admitted for a recurrent pulmonary embolism%
\end{abstract}%



\sloppy


\textbf{Introduction}

Pulmonary embolism (PE) is a major cause of death worldwide (1). The
risk factors are well described and classified by the European Society
of Cardiology (ESC) in three categories~: Strong, moderate and weak risk
factors (2). The strong risk factors included generally~: trauma of the
lower limb or spinal cord, hip or knee replacement, hospitalization for
heart failure or atrial fibrillation/flutter, myocardial infarction
within previous three months and previous venous thromboembolism (2).
Even if pulmonary embolism is rare in young adult, the causes are the
same as in the adults (3). The recurrence of thromboembolism is
generally associated to malignancy or thrombophilia (4). The most
frequent occult malignancies during PE involved the lung,
gastrointestinal tract, breast, and uterus (5). This is the reason why
the screening of these cancers is systematic in the management of
pulmonary embolism (2). Association between brain tumors and pulmonary
embolism is rare. Some cases have been described mainly in perioperative
period for craniectomy and the risk factors included~: older age, motor
deficit, high grade gliomas (6,7). We describe a rare case of recurrent
pulmonary embolism in a young man with occult brain tumor. This case is
important because it reinforces the need of critical and
multidisciplinary assessment of thromboembolism in young patients before
considering it as idiopathic.

\textbf{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\textless{}14 pg/ml) NT pro
NBP at 14 pg/ml (normal range\textless{}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.

\textbf{Discussion}

Pulmonary embolism (PE) is a major cardiovascular disease which could be
potentially life-threatening (1)\textbf{.} Pre-existing malignancy is
one of the most common etiology in recurrent forms. (4). The most
frequent occult malignancies during PE involved the lung,
gastrointestinal tract, breast, and uterus (5). These malignancies are
generally diagnosed at the advanced stage of the disease (8). The
pathophysiology of malignancy associated with thromboembolism include~:
hypercoagulable state due to many factors including release of
inflammatory cytokines, activation of the clotting system, expression of
hemostatic proteins on tumor cells, inhibition of natural
anticoagulants, and impaired fibrinolysis (9). Brain tumors like ovary
and pancreatic cancers even if rare in terms of prevalence are strongly
associated with thromboembolic events (10). This is illustrated by the
fact that 11-20\% of patients with brain tumors have pulmonary embolism
and the median time to develop the disease in generally 6.5 years after
the diagnosis of the tumor (11). Our patient was followed for a
depression since 5 months before the diagnosis of the second episode of
pulmonary embolism. We think that the first episode of pulmonary
embolism during childhood could be due to a provoked cause (knee
trauma). Glioblastoma is known as the main brain tumor and the most
associated with pulmonary embolism (11). The radiological presentation
of the mass evoked this diagnosis, even if the final diagnosis is done
by histopathologic studies. At the early stage of the disease, MRI of
the brain is the most sensitive tool for the diagnostic of Glioblastoma
isointensity to hypointensity on T1WI, hyperintense ill-defined lesions
on T2WI, little or no mass edema, and no contrast enhancement (12).
CT-Scan could evoked hypervascularised brain tumor, but the difference
between primitive lymphoma or glioblastoma is difficult by imaging (13).
Knowing that the patient was immunocompetent and the lesion was
polylobular and heterogenous contrary to lymphoma we have retained the
diagnosis of glioblastoma. But this diagnosis will be well investigated
by the neurosurgical team. The presence of signs of herniation signify
that the tumor was advanced. This case suggest that the physician should
be more aware and thoroughly examine young patients with pulmonary
embolism in order to exclude potential life-threatening conditions like
malignancy.

\textbf{Conclusion~:}

Brain tumor is a potentially life-threatening cause of pulmonary
embolism even in young. A good clinical assessment associated with
extensive paraclinical workups should be made before concluding on an
idiopathic cause especially in case of recurrence.

\textbf{Abbreviations}

AFP: Alpha foetoprotein

CEA: Carcino-embryonic Antigen

CT: Computed Tomography

ESC: European Society of Cardiology

HIV: Human Immunodeficiency Virus

NSE: Neuron Specific Enolase

PE: Pulmonary Embolism

PSA: Prostate Specific Antigen

\textbf{Diclosures}

\textbf{Approval of the research protocol:} Formal ethical approval from
the University Research Ethics Board was not required for the completion
of this study.

\textbf{Informed consent:} Written informed consent for publication of
this case report was obtained from the patient.

\textbf{Data Availability Statement~:} The data that support the
findings of this study are available from the corresponding author upon
reasonable request.

\textbf{Registry and registration no. of the study} : N/A.

\textbf{Animal studies:} N/A.

\textbf{Conflict of interest:} None

\textbf{Funding:} None

\textbf{Author Contribution~:}

Management of the case~: All the authors

Manuscript writing~: MNT

Critical revision~: AO

Supervision~: SC

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