S3754 Crohn’s Disease-Associated Hypercoagulability Presenting as Massive Pulmonary Embolism and Clot in Transit: A Case of Cardiac Arrest and Survival

Introduction: Crohn’s disease, a chronic inflammatory bowel disorder, is increasingly recognized as a systemic disease with thromboembolic risk. Venous thromboembolism (VTE) occurs in up to 3 times more frequently in patients with inflammatory bowel disease (IBD), especially during active flares. Clot in transit is a rare and life-threatening finding often preceding massive pulmonary embolism (PE), and early recognition is critical. Case Description/Methods: A 42-year-old woman with asthma, ADHD, and Crohn’s disease presented with worsening dyspnea and fatigue for 2 weeks following a flu-like illness. She was using nebulizers more frequently and reported needing assistance with basic tasks due to breathlessness. In the emergency department, she was tachypneic, hypoxic, and cyanotic. Despite BiPAP support, she progressed to respiratory failure and was intubated. Bedside echocardiogram revealed a mobile clot in transit near the tricuspid valve. A stat CTA chest confirmed a massive bilateral PE. While being stabilized in the ICU, the patient went into cardiac arrest with pulseless electrical activity (PEA). Advanced Cardiac Life Support (ACLS) protocol was initiated, and return of spontaneous circulation (ROSC) was achieved after 3 rounds of epinephrine. Full-dose tenecteplase was administered during the code. The patient underwent emergent suction thrombectomy. Hypercoagulable workup including antiphospholipid antibody panel was negative. Her recent Crohn’s symptoms and elevated inflammatory markers suggested an active flare as the likely trigger of the hypercoagulable state. She recovered and was discharged on apixaban. Discussion: This case highlights a rare, fulminant presentation of Crohn’s disease-associated hypercoagulability leading to massive PE with clot in transit and cardiac arrest. The absence of traditional hypercoagulable conditions, recent infection, and her Crohn’s history point toward inflammation-induced thrombosis. Inflammatory bowel disease promotes thrombogenesis via endothelial activation, elevated cytokines (TNF-α, IL-6), platelet hyperactivity, and impaired fibrinolysis. Clinicians must maintain vigilance for PE in IBD patients with unexplained respiratory symptoms, even in outpatient settings. Early diagnosis and aggressive intervention, including thrombolytics and thrombectomy, can be lifesaving.