Possibility Of Pulmonary Embolism Research Articles

Chronic Thromboembolic Pulmonary Hypertension Presented with Dyspnea on Exertion: A Case Report

<p>慢性血栓栓塞性肺高壓是一種罕見、嚴重且持續惡化的肺部血管性疾病，隨病程進展，致死率極高，儘早鑑別診斷，方能提供準確治療計劃。本文是一位67歲女性案例，因活動呼吸喘就醫， 初步臆斷為心臟衰竭合併急性惡化，入院後藉由病史詢問、檢驗及理學檢查結果顯示BNP持續上升且心電圖呈現S1Q3T3，初步懷疑可能有肺栓塞併心衰竭，故安排心臟超音波檢查，結果發現有肺動脈高壓（肺動脈壓：62.3 mmHg）與右心衰竭，安排胸部電腦斷層攝影，顯示肺動脈栓塞，隨即召開家庭會議解釋病情後，接受右心導管合併肺動脈血管攝影檢查，最終確診為遠端型慢性血栓栓塞性肺高壓併右心衰竭。經由醫療團隊評估後，治療計劃即以藥物為主，故協助申請標靶藥物Riociguat。針對此類病人，即便臨床表徵不具特異性，仍可依病史詢問、檢驗及理學檢查預測肺栓塞的可能性，之後進入影像學鑑別診斷。換言之，雖然慢性血栓栓塞性肺高壓有其高致命的危險性，倘若能及早做出診斷與治療，便能降低死亡風險。</p> <p> </p><p>Chronic thromboembolic pulmonary hypertension is a rare, severe and continuous deterioration of pulmonary vascular disease which has high mortality rate along with disease progression. Earlier di­agnosis could contribute to a more accurate treatment plan. A case of 67-year-old female was admitted to hospital because of exertional dyspnea. She was initially suffering from heart failure with acute deterioration. After admission, the results of medical history inquiry, laboratory data and physical ex­amination revealed that BNP level kept raising and the electrocardiogram showed S1Q3T3, which pul­monary embolism with heart failure was suspected. Therefore, echocardiography revealed pulmonary hypertension (pulmonary artery pressure: 62.3 mmHg) and right heart failure. Pulmonary embolism was noticed on chest computed tomography. Soon after the family meeting of medical condition dis­cussion, the patient received right heart catheterization combined with pulmonary artery angiography, and the final diagnosed is distal chronic thromboembolic pulmonary hypertension with right heart failure. After medical team’s assessment, the treatment plan was based on armaceutical control. Thus, the target therapy of Riociguat was performed. For such type of patients, even with non-specific symptoms, the possibility of pulmonary embolism can still be predicted based on medical history, lab­oratory data, physical examination, and the imaging differential diagnosis. If diagnosis and treatment can be conducted as early as possible, the high mortality rate of chronic hromboembolic pulmonary hypertension can be reduced.</p> <p> </p>

A case of extra-nodal natural killer/T cell lymphoma presenting as rhinorrhea and blindness

Extra-nodal natural killer/T cell lymphoma (EN-NK/T) is a highly uncommon, aggressive, mature T or NK-cell lymphoma with a high fatality rate. It has a propensity for infiltrating tissues and spreading to the eye. EN-NK/T-NT is marked by polymorphic clinical characteristics, which can make diagnosis difficult and cause delayed management. This report details a 63-year-old Iranian woman who presented initially with left ocular involvement of unknown cause. Ethmoidal sinusitis, upper nasal obstruction, right proptosis, dacryocystitis, and pulmonary nodules developed later as her disease progressed. Biopsies of the orbit, ethmoidal sinus, and pulmonary nodules were significant for EN-NK/T cell lymphoma. The patient developed and was treated for Covid-19. Due to the progressive lymphoma, chemotherapy was initiated after recovery from Covid-19. After starting the first course of chemotherapy, the patient's condition deteriorated rapidly with the possibility of pulmonary embolism, and she expired inAugust, 2021 2021. This case highlights the diagnostic difficulty of EN-NK/T cell lymphoma and demonstrates its rarity and ability to mimic other diseases.

Splinter hemoragije kao mogući znak infarkta miokarda i plućne embolije

Introduction/Objective Subungual splinter haemorrhages (SSH) are a common non-specific clinical sign which is easy to recognize. They can occur in conjunction with many medical conditions of various significance. They present as painless black longitudinal lines towards the distal part of the nail bed. The objective of this article is to present a patient with newly acquired chest pain, a differential diagnostic dilemma between acute myocardial infarction (AMI) and pulmonary embolism (PE) whose fingers show signs of SSH. Case report An emergency medical team (HMP) was dispatched to a location where a 58-year-old man was experiencing chest pain. They found the patient in a sitting position, reporting sudden onset of stabbing chest pain with no propagation and lasting a few hours. He stated that he had never before had similar symptoms. Upon examination, the patient was afebrile, hypertensive (180/100 mmHg), mildly tachycardic (84/min), and blood oxygen saturation was within normal limits (97% on room air). ECG: sinus rhythm, left axis deviation, S1 in D1, ST elevation ≤ 1mm in D2, D3 and aVF, ST depression from V4 to V6. The physical examination revealed SSH located on the nail beds of the hands distally. The patient was transported to cardiology where he was continuously monitored. Rising values of troponin T (310, 2628, 1507 ng/l) and creatine kinase (934, 1228 U/l) were noted. However, based on the rising values of D dimer and pulmonary artery multislice computer tomography (MSCT) findings, there were reasons to consider the possibility of pulmonary embolism (PE) as well. Conclusion Future research should aim at defining the connection between SSH and AMI and/or PE. This would be crucial in making a prehospital diagnosis, especially in countries that have huge cardiovascular disease public health problems, such as ours. A quick and simple exam of nailbeds on the hands of patients with symptoms of AMI/PE, but without significant ECG findings, could help with the differential diagnosis if SSH were found to be present.

Pulmonary Embolism in Vaccine-Induced Thrombotic Thrombocytopaenia: Under-Reported?

Vaccine-induced thrombotic thrombocytopenia (VITT) is a rare, newly described syndrome characterised by thrombocytopenia and thrombosis 5–24 days after administration of an adenoviral vector-based COVID-19 vaccine. It resembles heparin-induced thrombocytopenia and, therefore, diagnostics and treatment are similar. Early recognition is essential to avoid potentially fatal outcomes. This article describes a case of VITT with symptomatic cerebral venous-sinus thrombosis and splanchnic vein thrombosis, as well as asymptomatic pulmonary embolism in a 49-year-old male. The authors discuss VITT, focusing on the possibility of pulmonary embolism being under-reported, diagnostic criteria, differential diagnosis, and treatment.

PULMONARY THROMBOEMBOLISM IN A CHILD AFTER BURN INJURY

Pulmonary embolism is rarely diagnosed in pediatric burn patients and is often only discovered at autopsy. Herein we would like to present the case of a pediatric patient with pulmonary thromboembolism who was burnt by hot water at home. A 4-year-old girl who was treated at an external center for 9 days due to second degree burn injuries in both legs. After the discharge she had suddenly become restless and than gone unconscious. Since pulmonary thromboembolism was suspected as the cause of cardiopulmonary arrest, a pulmonary computed tomography angiogram was taken, which showed a thrombus in the lobar and segmental branches of the right pulmonary artery supplying the right lower lobe. Enoxaparin sodium treatment (2×1mg/kg) was initiated. At day 16, a control computed tomography angiogram showed that the thrombus in the lobar and segmental branches of the pulmonary artery had disappeared. This case report illustrates the importance of chemoprophylaxis against pulmonary embolism in both pediatric and adult burn patients. In such cases, especially the severe ones, a sudden deterioration of patient’s clinical status in the form of respiratory distress or failure should raise suspicion about the possibility of pulmonary embolism.

Coagulation factor IV is an indicator of symptomatic pulmonary embolism in patients with primary lung cancer.

Coagulation factor IV, also known as serum ionised calcium (SIC), participates in coagulative process and tends to elevate in patients with primary lung cancer. It may be an indicator of symptomatic pulmonary embolism (PE) due to primary lung cancer (LC). A total of 388 patients who underwent CTPA and/or radionuclide ventilation perfusion scanning due to PE-suspected symptoms were stratified into LCPE (lung cancer and PE) group (n=95), PE group (n=99), LC group (n=98) and control group (n=96). At admission, the level of SIC and STC (serum total calcium) was compared among four groups. At discharge, the level change of SIC and STC from admission to discharge was compared among four groups. The coefficients analysis between SIC as well as STC and the possibility of PE were performed. The SIC of LCPE group was the highest among four groups at admission (P<0.001). The level change of SIC from admission to discharge in LCPE group was the highest among four groups (P=0.001). A ROC curve analysis demonstrated that the sensitivity and specificity of SIC for a diagnosis of PE among LC patients were 71.9% and 86.0%, respectively. The area under curve (AUC) was 0.781. Along with the increase of 0.1mmol/L in SIC level, the risk ratio for a PE was 2.165 (1.537-2.849) (P<0.001). Serum ionised calcium may be an indicator of pulmonary embolism in patients with primary lung cancer.

Pulmonary Embolism Caused by Intravenous Leiomyosarcoma of the Lower Limb.

Pulmonary embolism (PE) is usually caused by thrombosis or tumor. We report the long-term survival of a patient with PE due to a leiomyosarcoma in the deep vein. A 71-year-old woman complained of dyspnea and swelling of the left lower limb. Computed tomography revealed filling defects in the pulmonary arteries and deep vein. She was diagnosed with PE caused by venous thrombosis and treated with anticoagulant therapy. Her symptoms were prolonged, and D-dimer tests remained negative. Biopsy of the substance in the deep vein revealed leiomyosarcoma. The possibility of PE caused by extravascular or intravascular tumors should be considered when a patient is negative for D-dimer.

Medication Safety

Medication Safety

High altitude pulmonary edema (HAPE) with pulmonary embolism

High altitude pulmonary edema (HAPE) is a life-threatening condition occurring at heights above 2500 meter mostly within 2-4 days of entry in high altitude. Postmortem studies showed evidence of thrombi in cases of HAPE suggesting possible role of thrombosis in the pathogenesis of HAPE. Here, we are presenting the two cases of HAPE with pulmonary embolism, and the possibility of pulmonary embolism should be considered in cases of HAPE with persistent radiographic opacities despite oxygen or descent.

Ankylosing spondylitis and risk of venous thromboembolism: A systematic review and meta-analysis.

Background:Several immune-mediated inflammatory disorders, such as rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus have been linked to an increased risk of venous thromboembolism (VTE). However, the data on ankylosing spondylitis (AS) are limited.Methods:We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing the risk of VTE and possible pulmonary embolism (PE) in patients with AS versus non-AS participants. Pooled risk ratio and 95% confidence intervals were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.Results:Of 423 potentially relevant articles, three studies met our inclusion criteria and thus, were included in the data analysis. The pooled risk ratio of VTE in patients with AS was 1.60 (95% confidence interval: 1.05–2.44). The statistical heterogeneity of this study was high with an I2 of 93%.Conclusion:Our study demonstrated a statistically significant increased VTE risk among patients with AS.

Scintigraphic Evidence for Overdiagnosis of Small PE on CT Pulmonary Angiography.

A 68-year-old man with recent history of a fall presented with dyspnea on exertion, and underwent computed tomography pulmonary angiography (CTPA) for possible pulmonary embolism (PE). The CTPA was first read by the radiology resident as nondiagnostic for segmental PE. Subsequent planar perfusion (Q) images were normal; meanwhile, the attending radiologist revised the CTPA results as subsegmental PE in the left upper lobe. Further Q-SPECT images were obtained and fused with CTPA for clarification, which showed normal perfusion in the region of PE. The patient was monitored without anticoagulation treatment and remained uneventful for 12months. This case illustrates that CTPA can lead to overdiagnosis and overtreatment of nonocclusive subsegmental PE.

Pulmonary Embolism presenting as Syncope

The diagnosis of Pulmonary embolism can easily be missed if it is not considered as one of the major differential diagnosis in a case of syncope without chest pain. We describe a case of a 74years old female with pulmonary embolism induced syncope, which highlights one of the difficulties in diagnosing pulmonary embolism. In a patient presenting in syncope without chest pain but raised troponin, the possibility of pulmonary embolism should also be considered if it does not fit with myocardial infarction. Otherwise, the diagnosis can be easily missed and patients may not receive appropriate treatment resulting in increased mortality. Pulmonary embolism should be considered in the differential diagnosis of every syncopal event in Emergency department and Cardiac care units. DOI: http://dx.doi.org/10.3126/njh.v12i1.12343 Nepalese Heart Journal Vol.12(1) 2015: 37-41

Effectiveness of MR angiography for the primary diagnosis of acute pulmonary embolism: clinical outcomes at 3 months and 1 year.

To determine the effectiveness of MR angiography for pulmonary embolism (MRA-PE) in symptomatic patients. We retrospectively reviewed all patients whom were evaluated for possible pulmonary embolism (PE) using MRA-PE. A 3-month and 1-year from MRA-PE electronic medical record (EMR) review was performed. Evidence for venous thromboembolism (VTE) (or death from PE) within the year of follow-up was the outcome surrogate for this study. There were 190 MRA-PE exams performed with 97.4% (185/190) of diagnostic quality. There were 148 patients (120 F: 28 M) that had both a diagnostic MRA-PE exam and 1 complete year of EMR follow-up. There were 167 patients (137 F: 30 M) with 3 months or greater follow-up. We found 83% (139/167) and 81% (120/148) MRA-PE exams negative for PE at 3 months and 1 year, respectively. Positive exams for PE were seen in 14% (23/167). During the 1-year follow-up period, five patients (false negative) were diagnosed with DVT (5/148 = 3.4 %), and one of these patients also experienced a non-life-threatening PE. The negative predictive value (NPV) for MRA-PE was 97% (92-99; 95% CI) at 3 months and 96% (90-98; 95% CI) with 1 year of follow-up. The NPV of MRA-PE, when used for the primary diagnosis of pulmonary embolism in symptomatic patients, were found to be similar to the published values for CTA-PE. In addition, the technical success rate and safety of MRA-PE were excellent.

Factor V Leiden Thrombophilia in a Female Collegiate Soccer Athlete: A Case Report

To raise awareness among health care providers caring for an active population to an uncommon genetic mutation that increases the risk for a potentially fatal venous thromboembolism. A 19-year-old previously healthy female collegiate soccer athlete complained of coughing and progressively decreased exercise tolerance, which were attributed to a recent illness and lack of sleep. Later that evening, she complained of dyspnea and pleuritic pain and was referred to the emergency department. Bilateral pulmonary emboli were identified with computed tomography, and a hypercoagulable panel revealed that the patient was heterozygous for the factor V Leiden mutation. Pneumonia, pneumothorax, pericarditis, pleuritis, gastroesophageal reflux disease, pulmonary embolism. Intravenous heparin therapy was initiated immediately in the emergency department. This was followed by inpatient anticoagulant therapy for 5 days and outpatient anticoagulant therapy for an additional 12 months. During this time, the patient was unable to participate in soccer drills or return to competition and was limited to conditioning activities due to the risk of increased bleeding time. Documented cases of pulmonary embolism in a young athletic population are rare and are usually associated with genetic risk factors. Factor V Leiden is a relatively uncommon genetic mutation that dramatically increases the risk for venous thromboembolism. Although the fatality rate in this population is low, fatality is preventable if the condition is recognized early and managed properly. Athletes should be encouraged to communicate with their athletic trainers regarding any changes in health status or medication usage. When an athlete presents with nonspecific symptoms such as dyspnea and chest pain, athletic trainers should consider the possibility of pulmonary embolism. A high degree of suspicion results in early diagnosis and treatment and may prevent a fatal event.

Significance of Reflux of Contrast Medium Into the Inferior Vena Cava on Computerized Tomographic Pulmonary Angiogram

Reflux of contrast medium into the inferior vena cava (IVC) is often detected on computerized tomographic pulmonary angiogram. The potential clinical implications and associated diagnoses of this finding have not been established. We investigated the prevalence and significance of reflux of contrast medium into the IVC in a large cohort of patients evaluated for possible pulmonary embolism (PE) by computerized tomographic pulmonary angiography. We retrospectively reviewed 1,065 consecutive computerized tomographic pulmonary angiographic examinations performed from January 1, 2007 through January 7, 2008 for the presence of reflux. Degree of reflux into the IVC and hepatic veins was graded from 1 (none) to 6 (severe). Patients' charts were reviewed for diagnoses during the index hospitalization and for background diseases. These clinical data were correlated with the reflux grade. The final study included 967 computerized tomographic pulmonary angiographic scans of 367 men and 600 women (mean age 62 ± 20 years, range 17 to 103). Almost 1/2 (480, 49.6%) had grade 1, 310 (32.1%) had grades 2 to 3, and 177 (18.3%) had grades 4 to 6. Multivariate logistic regression found that pulmonary hypertension, history of congestive heart failure, chronic atrial fibrillation, and acute PE were associated with extensive reflux (grades 4 to 6) with odds ratios (95% confidence intervals) of 5.4 (3.0 to 9.9, p <0.001), 3.7 (2.3 to 6.1, p <0.001), 2.3 (1.0 to 5.3, p = 0.044), and 1.8 (1.2 to 2.9, p = 0.011), respectively. Interobserver agreement between the 2 readers for reflux grading was good (kappa = 0.77). In conclusion, extensive reflux of contrast medium into the IVC detected on computerized tomographic pulmonary angiogram may serve as a pathophysiologic marker of right heart dysfunction, specifically pulmonary hypertension, congestive heart failure, chronic atrial fibrillation, or PE.

Internal jugular vein thrombosis associated with venous hypoplasia and protein S deficiency revealed by ultrasonography

A 41-year-old woman, who had no thrombotic risk factors and past history except congenital scoliosis, underwent central venous catheterization (CVC) before correction of the scoliosis. When internal jugular vein (IJV) catheterization using the anatomical landmark technique failed, CVC under ultrasound guidance was tried. As a consequence, thrombosis and hypoplasia of the right IJV were incidentally detected by ultrasonography. Central venous catheters were then successfully placed in other veins under ultrasound guidance. Also, after examinations to rule out the possibility of pulmonary embolism and to clarify the causes of the IJV thrombosis, the patient was found to have protein S deficiency. CVC under ultrasound guidance should be recommended to prevent the failure of cannulation and complications such as thromboembolism in patients who could possibly have anomalies of vessels as a result of anatomical deformities caused by severe scoliosis, even if patients do not have thrombotic risk factors such as a history of central catheter insertion or intravenous drug abuse, cancer, advanced age, cerebral infarction, and left ventricular dysfunction. Also, if venous thrombosis is found in patients without predisposing risk factors, one should ascertain the cause of the hypercoagulable state, for example protein S deficiency, and perform appropriate treatment and prevention of venous thromboembolism.

A pilot audit of a protocol for ambulatory investigation of predicted low-risk patients with possible pulmonary embolism

Patients with possible pulmonary embolism (PE) commonly present to acute medical services. Research has led to the identification of low-risk patients suitable for ambulatory management. We report on a protocol designed to select low-risk patients for ambulatory investigation if confirmatory imaging is not available that day. The protocol was piloted in the Emergency Department and Medical Assessment Area at the Royal Infirmary of Edinburgh. We retrospectively analysed electronic patient records in an open observational audit of all patients managed in the ambulatory arm over five months of use. We analysed 45 patients' records. Of these, 91.1% required imaging to confirm or refute PE, 62.2% received a computed tomography pulmonary angiogram (CTPA). In 25% of patients, PE was confirmed with musculoskeletal pain (22.7%), and respiratory tract infection (15.9%) the next most prevalent diagnoses. Alternative diagnoses was provided by CTPA in 32% of cases. We identified no adverse events or readmissions but individualised follow-up was not attempted. The data from this audit suggests this protocol can be applied to select and manage low-risk patients suitable for ambulatory investigation of possible PE. A larger prospective comparative study would be required to accurately define the safety and effectiveness of this protocol.

Asymmetric septal hypertrophic cardiomyopathy: a case report

We report the case of a 30-year-old female who presented to the emergency department with the chief complaint of syncope. She also described intermittent chest pain and exertional dyspnea over the past several weeks. Review of systems and laboratory findings including D: -dimer levels were noncontributory. EKG demonstrated right bundle branch block. Nongated chest CT with contrast was ordered to exclude the possibility of pulmonary embolism demonstrating markedly asymmetric septal thickening. Suspicion for hypertrophic cardiomyopathy was raised, which was subsequently confirmed on gated cardiac MRI.

The Pulmonary Embolism Rule-Out Criteria rule in a community hospital ED: a retrospective study of its potential utility

Background The Pulmonary Embolism Rule-Out Criteria (PERC) rule identifies patients who can be safely discharged from the emergency department (ED) without undergoing laboratory or radiological investigation for possible pulmonary embolism (PE). It was shown to be 99% sensitive in a large validation series. Our objective was to assess the PERC rule's performance in a representative US community hospital. Methods A chart review of ED patients receiving computed tomographic scans (CTS) for possible PE during a 4-month study period was performed. The PERC rule was applied to this cohort, and its sensitivity and negative predictive value were determined. Results Two hundred thirteen patients underwent chest CTS to “rule out” PE. Forty-eight patients met PERC rule criteria, and all had negative CTS. Of the remaining 165 patients, 18 patients (11%) had scans positive for PE. The overall prevalence of PE was 8.45% (95% CI, 5.22-13.24%). The PERC rule's sensitivity was 100% (95% CI, 78.12-100%), with a negative predictive value of 100% (95% CI, 90.80-100%). Application of the PERC rule at the point-of-care would have reduced CTS by 23%. Conclusions In our community hospital, the PERC rule successfully identified ED patients who did not require CTS evaluation for PE. Had the PERC rule been applied, nearly one-quarter of all CTS performed to “rule out PE” could have been avoided.

Systematic effects of surgical treatment of hip fractures: Gliding screw-plating vs intramedullary nailing

Aim Numerous studies have been published regarding the comparison between intramedullary nail and the dynamic hip screw and plate for the fixation of intertrochanteric fractures in elderly patients. In this paper we present a comparative study of these two methods regarding their systemic effects on this group of patients. Materials–methods This is a randomized trial of 120 consecutive patients with an intertrochanteric fracture treated with either extramedullary fixation (dynamic hip screw and plate; DHS, Synthes-Stratec, Oberdorf, Switzerland) or intramedullary nail (Gamma nail, Stryker Howmedica, Freiburg, Germany and Endovis BA, Citieffe, Bologna, Italy). The parameters that we assessed pre-operatively, in addition to their demographics, included their mental state (MMSE), their nutritional and immune state and their pulmonary function. Intra-operatively we calculated the amount of radiation exposure, the amount of blood loss and the length of operative time for each procedure. Postoperatively we repeated the calculation of the mental and pulmonary state and the blood loss, during days 1, 3, and 10 and related them to the ease of the patient's mobilization. Results Decreased bleeding and post-operative pain, reduced post-operative morbidity and faster recovery of function were better but not significant in the group of intramedullary fixation (all p > 0.05). However, in the same group there were slightly more patients in whom the MMSE was falling, together with their pulmonary function, suggesting that this method probably predisposes to higher chances of pulmonary dysfunction and the possibility of pulmonary embolism. Conclusion We found no significant differences between the two methods of stabilization of these fractures regarding their systemic effects perioperatively. The classic dynamic hip screw can preserve its position as a safe and effective solution for these already vulnerable patients having sustained a trochanteric fracture against the novel intramedullary techniques.