Pylephlebitis presenting as spontaneous coronary sinus thrombosis: a case report

BACKGROUND: Coronary sinus thrombosis is a rare phenomenon. When identified, it most often is a complication of infective endocarditis or procedural intervention. We present an unusual and unreported case of spontaneous coronary sinus thrombosis as embolic sequela of an intra-abdominal infectious process. CASE PRESENTATION: We report a case of a 61-year-old white woman with a history of end-stage renal disease on hemodialysis, paroxysmal atrial fibrillation not on long-term systemic anticoagulation, and history of recurrent diverticulitis that presented with acute onset abdominal pain and nausea. Computed tomography of her abdomen and pelvis with intravenous contrast was negative for acute intra-abdominal pathology, but incidentally identified an oval-shaped filling defect at the ostium of the coronary sinus suspicious for thrombus or mass which was confirmed on subsequent transesophageal echocardiogram. In light of her concomitant transaminitis but otherwise negative workup, the mass was believed to be thromboembolic in nature, originating within the hepatic venous system as a manifestation of recurrent diverticulitis with associated pylephlebitis and ultimately lodging into the coronary sinus. With the newly detected thrombus and history of paroxysmal atrial fibrillation, she was started on warfarin for therapeutic systemic anticoagulation that resolved her clot by 3-month follow up. CONCLUSIONS: Although coronary sinus thrombosis is rare, a high index of suspicion and close scrutiny of the venous system in patients with intra-abdominal infectious processes would prevent delay in management of this potentially serious complication. The discussion of this case highlights the anatomy of the cardiac venous system, the pathophysiology of thrombus formation, and the utility of transesophageal echocardiography in confirming a diagnosis and assessing treatment efficacy.