Massive pulmonary embolism in a Lebanese patient doubly heterozygous for MTHFR and Factor V Leiden presenting with syncope and treated with tenecteplase

Abstract

A 54-year-old man, with a past history of hypertension and non-insulin-dependent diabetes, presented to the emergency department following a collapse at home. The patient had reported to his family left calf pain after driving for several hours. The patient denied the presence of history of varicose veins, history suggestive of episodes of thrombotic events in the legs or strokes and family history was negative for thrombotic events. Thereafter the patient fell down after standing up and developed severe shortness of breath with chest compressive feeling. On examination, he was plethoric and diaphoretic, but apyrexial. His pulse rate was 115 per min and regular, with a systolic blood pressure of 60 mmHg. His respiratory rate was 28 per min, and oxygen saturation was 91% on room air. Auscultation of his lungs and heart was unremarkable, as was the examination of his abdomen. His left lower leg was noted to be 3 cm larger in diameter than the right, 3 cm below the level of the anterior tibial tuberosity. A large bore intravenous cannula was sited in each antecubital fossae. Arterial blood gas analysis (performed at the above level of oxygen supplementation) revealed a pH of 7.36, with a pCO2 of 30.6, pO2 of 60.5, and HCO3 of 17. An electrocardiogram demonstrated sinus tachycardia, with minor anterolateral ST segment depression, with T wave inversion in lead V I, an ‘SI, QIII, TIII’ pattern, and an incomplete right bundle branch block (IRBBB) (figure 1). Chest X-ray was unremarkable. A bedside ultrasound scan revealed left popliteal vein thrombosis, and a bedside echocardiography