To present a case of a 69-year-old female with 5-month history of jaundice, anemia and exertional dyspnea.

Her diagnostics showed negative for Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome. There are no episodes of overt bleeding and was negative for Fecal Immunochemical Test. Her 2D echo and Bone Marrow Aspiration Biopsy showed unremarkable results. Chest CT scan demonstrated an incidental finding of a floating aortic thrombus, spindle-shaped filling defect, from the aortic arch distal to the origin of the left subclavian artery extending approximately 9.8 cm in length down to the level of T9 to T10. Laboratory tests showed presence of cold agglutinin, positive for Direct Coombs Test, elevated LDH, hemoglobin less than 8g/dL and monoclonal serum IM KAPPA monoclonal component, which are congruent with Autoimmune Hemolytic Anemia, Cold Agglutinin Disease in hypercoagulable state. The therapeutic management for aortic thrombosis remained controversial. However, the main strategy is still conservative pharmacotherapy. There is no definite evidence as to the antithrombotic therapy or the appropriate duration of treatment. However, the patient is in hypercoagulable state of Cold Agglutinin Disease, recommendations were low molecular-weight heparin for treatment and prophylaxis for thrombosis. Hence, patient was started on anticoagulation, Enoxaparin at 1mg/kg subcutaneously every 12 hours, Aspirin 80mg once daily, and Atorvastatin 80mg once daily. Patient was also started on Rituximab for her Cold Agglutinin Disease. Patient was eventually discharged stable.

After 3 months on anticoagulation, antiplatelet and statin, her repeat PET/CT scan showed complete resolution of floating aortic thrombus. On her succeeding follow-ups, patient did not present with any symptoms of distal embolization, her jaundice improved and eventually resolved, and her hemoglobin increased to normal level. On her 6-month follow-up, patient still did not manifest any symptoms of embolization nor recurrence of jaundice or anemia. Enoxaparin was discontinued and patient remained asymptomatic.

Floating thoracic aortic thrombus are prone to break-off and may lead to embolic events with fatal consequences. Underlying cause should be investigated and treated as necessary. Early detection and treatment, whether medical or surgical, could lead to favorable prognosis.