Wormshaped thrombus mimicking Chiari's network in a cocaine user

A 20 year old man, with a history of cocaine and amphetamine abuse, was admitted to the coronary care unit with mild exertional dyspnoea. His ECG and cardiac enzymes were normal. A transthoracic echocardiogram showed a dilated and hypokinetic left ventricle with a large sessile apical thrombus and the presence of a long and thin mass in the right atrium. The right ventricle was normal. A transoesophageal echocardiogram revealed a filiform, worm shaped type A thrombus (arrow) in the right atrium simulating Chiari’s network, the Eustachian’s valve embryonal residuum, floating freely in the cavity and coming from the inferior vena cava lumen. The patient was treated with a 10 mg intravenous bolus of recombinant tissue plasminogen activator (rt-PA) followed by a continuous infusion of 90 mg rt-PA over two hours. Following thrombolytic treatment the right atrial serpiginous thrombus and apical thrombus disappeared. The patient was discharged 10 days later in excellent general condition on oral anticoagulant treatment. Chronic abuse of cocaine can induce endothelial alterations allowing thrombus formation. Serpiginous and mobile thrombus can simulate Chiari’s network causing a difficult differential diagnosis.