Occult tumor presenting with bilateral CRVO
B. Perform a thoracoabdominopelvic computed tomography scan
The fundus findings were consistent with bilateral CRVO. An extensive hypercoagulability and autoimmune workup producing normal results raised the suspicion of an underlying paraneoplastic syndrome. The patient was sent for an urgent thoracoabdominopelvic computed tomography scan that revealed a right paratracheal adenopathy conglomerate with a dimension of 39 × 28 × 62 mm (Figure 2) and a thrombosis of the middle suprahepatic veins (Budd-Chiari syndrome). Meanwhile, the patient promptly initiated anticoagulation treatment with enoxaparin 1 mg/kg every 12 hours. Endobronchial ultrasound–guided transbronchial needle aspiration biopsy and anatomopathological results were inconclusive. A positron emission tomography scan was performed. In addition to the mediastinal mass, a supraclavicular adenopathy with increased fluorine 18–labeled fluorodeoxyglucose uptake was detected. A biopsy of this adenopathy revealed a poorly differentiated squamous cell carcinoma. To identify the primary tumor, extensive workups by gastroenterology, otorhinolaryngology, gynecology, and dermatology were performed. Despite the efforts, the primary location of the tumor was not identified. As such, the patient was diagnosed with an occult tumor and chemotherapy was initiated with carboplatin and placlitaxel.