Background: Aortic thrombi are uncommon and are typically associated with significant atherosclerosis or presence of an aneurysm. Patients with chronic myelomonocytic leukemia(CMML) are well known to be associated with arterial thrombosis, involving medium-sized and small-sized arteries. However, a large artery(aortic) thrombus has rarely been reported in patients with CMML. Todate there is no consensus on the management of this condition. Herein we describe a rare case of aortic thrombus with multiple visceral thromboembolism, subsequently diagnosed to have CMML.

Aims: We aim to raise the awareness of rare presentation of CMML as aortic thrombus with visceral thromboembolism, and summarise the pathophysiology as well as review the literature on current treatment options available.

Methods: We report here a Chinese gentleman who presented with fever and abdominal pain. Physical examination was unremarkable except for upper abdominal tenderness. A CT scan abdomen showed large mid-thoracic descending aortic mural thrombus and multiple splenic and renal infarcts. He was started on aspirin and enoxaparin. An extensive workup for the etiology of aortic thrombus was negative for infectious, cardiogenic, vasculitic and thrombophilic cause of arterial thromboembolism. Follow-up showed persistent anaemia with leucocytosis and thrombocytosis. A bone marrow study done revealed features suggestive of CMML.

Results: Patient was initially started on aspirin and enoxaparin, which was subsequently transitioned to rivaroxaban. He was also started on hydroxyurea, with which his haemoglobin, leucocyte and platelet counts have remained stable. He has remained well with no further thromboembolic episodes.

Conclusions: Aortic mural thrombi are rare in the absence of atherosclerosis or aneurysm. A thorough evaluation is necessary to determine the cause of thrombosis. Although anti platelet therapy is recommended for patients with uncomplicated aortic thrombus, presence of embolic phenomenon warrants treatment with anticoagulation. In addition, ethology-specific treatment may render these patients less thrombogenic, and patient may not need to be be continued on long term anticoagulation.

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ISTH Congress Abstracts - https://abstracts.isth.org/abstract/primary-aortic-thrombus-with-multiple-visceral-embolisation-a-presenting-manifestation-of-chronic-myelomonocytic-leukemia/