A large left atrium thrombus extended from the right lower pulmonary vein in a patient with malignant lymphoma

Ischemic stroke is a serious clinical problem that crucially needs to be prevented. The three major pathophysiological mechanisms leading to ischemic strokes are cardiac embolisms, atherosclerotic large-vessel disease, and intracranial small-vessel disease. Left atrial appendage (LAA) thrombi in patients with an atrial fibrillation (AF) are the well-studied cardiac thrombi known to cause ischemic stroke [1,2]. Fifteen to twenty percent of ischemic strokes were observed in patients with AF, and the annual risk of stroke in patients with non-valvular AF is as high as 5% [3]. Pulmonary vein thrombosis (PVT) is thought to be a rare complication of thoracic surgery or lung cancer; however, since 2012, several cases of PVT in elderly patients without these conditions have been reported, suggesting that PVT may be common in elderly patients. Additionally, a 2014 report found PVT in a young female [4], indicating PVT can exist in all populations. My previous manuscript reported that 35 out of 57 (61%) elderly patients with chest pain had PVT, and 17 of 35 (48.6%) patients with PVT had a connected thrombus in the left atrium, which was assessed using a 64-slice multidetector-computed tomography (64-MDCT) [5]. However, there have been no reports of a thrombus in the left atrium connecting to a pulmonary vein thrombus using transesophageal echocardiography (TEE). An 82-year-old Japanese male with malignant lymphoma was referred for the evaluation of edema. The patient was treated with dexamethasone (0.5 mg once daily). The patient had no cough, sputum or cerebral infarction present. The patient presented with edema of the left arm and both legs. Cardiac examination revealed no heart murmurs or arrhythmias. The patient's body-mass index (BMI) was 27.1. Lung examination was normal with no presentation of decreased breath sounds, lung crackles or wheezing. The patient had no history of warfarin treatment. The chest roentgenogram revealed a pleural effusion on the left side. The lymph nodes around the neck and the femoral artery had significant swelling. EKG indicated a normal sinus rhythm, a normal axis, no ST–T changes, and complete left bundle branch block; the patient's heart rate was 77 beats/min. In addition, the serum D-dimer level was 5.6 μg/ml (normal: b1.0 μg/ml), the activity of protein S was 55% (normal: 60–127%), and the activity of protein C was 140% (normal: 64–135%). Transthoracic echocardiography