Presentation Of Pulmonary Embolism Research Articles

Acute Abdomen Misdiagnosed as Leaking Aortic Abdominal Aneurysm: An Unusual Presentation of Pulmonary Embolism: Case Report

We are presenting a case study about a 62-year-old lady who presented to A&E with abdominal pain and hypotension. Initially her presentation was thought as leaking aortic aneurysm giving that all investigations done were inconclusive. CTAA was done accordingly which showed incidental finding of Pulmonary Embolism (PE). In Literature, we found few cases reported for PE with abdominal pain. Yet, our case discussed a unique presentation of PE with lower abdominal pain without desaturation of oxygen rather than upper abdominal pain with low oxygen saturation. Our case is supported with images of the CTPA and Chest X-ray. Our recommendation is that clinicians should consider PE as one of the differential diagnoses of acute abdomen due to its high mortality rate when misdiagnosed or missed diagnosed.

Identification of chronic thromboembolic pulmonary hypertension on CTPAs performed for diagnosing acute pulmonary embolism depending on level of expertise

BackgroundExpert reading often reveals radiological signs of chronic thromboembolic pulmonary hypertension (CTEPH) or chronic PE on computed tomography pulmonary angiography (CTPA) performed at the time of acute pulmonary embolism (PE) presentation preceding CTEPH. Little is known about the accuracy and reproducibility of CTPA reading by radiologists in training in this setting. ObjectivesTo evaluate 1) whether signs of CTEPH or chronic PE are routinely reported on CTPA for suspected PE; and 2) whether CTEPH-non-expert readers achieve comparable predictive accuracy to CTEPH-expert radiologists after dedicated instruction. MethodsOriginal reports of CTPAs demonstrating acute PE in 50 patients whom ultimately developed CTEPH, and those of 50 PE who did not, were screened for documented signs of CTEPH. All scans were re-assessed by three CTEPH-expert readers and two CTEPH-non-expert readers (blinded and independently) for predefined signs and overall presence of CTEPH. ResultsSigns of chronic PE were mentioned in the original reports of 14/50 cases (28%), while CTEPH-expert radiologists had recognized 44/50 (88%). Using a standardized definition (≥3 predefined radiological signs), moderate-to-good agreement was reached between CTEPH-non-expert readers and the experts’ consensus (k-statistics 0.46; 0.61) at slightly lower sensitivities. The CTEPH-non-expert readers had moderate agreement on the presence of CTEPH (κ-statistic 0.38), but both correctly identified most cases (80% and 88%, respectively). ConclusionsConcomitant signs of CTEPH were poorly documented in daily practice, while most CTEPH patients were identified by CTEPH-non-expert readers after dedicated instruction. These findings underline the feasibility of achieving earlier CTEPH diagnosis by assessing CTPAs more attentively.

Outcome of patients with different clinical presentations of high-risk pulmonary embolism.

AimsThe 2019 European Society of Cardiology (ESC) guidelines provide a revised definition of high-risk pulmonary embolism (PE) encompassing three clinical presentations: Cardiac arrest, obstructive shock, and persistent hypotension. This study investigated the prognostic implications of this new definition.Methods and resultsData from 784 consecutive PE patients prospectively enrolled in a single-centre registry were analysed. Study outcomes include an in-hospital adverse outcome (PE-related death or cardiopulmonary resuscitation) and in-hospital all-cause mortality. Overall, 86 patients (11.0%) presented with high-risk PE and more often had an adverse outcome (43.0%) compared to intermediate-high-risk patients (6.1%; P < 0.001). Patients with cardiac arrest had the highest rate of an in-hospital adverse outcome (78.4%) and mortality (59.5%; both P < 0.001 compared to intermediate-high-risk patients). Obstructive shock and persistent hypotension had similar rates of adverse outcomes (15.8% and 18.2%, respectively; P = 0.46), but the only obstructive shock was associated with an increased all-cause mortality risk. Use of an optimised venous lactate cut-off value (3.8 mmol/L) to diagnose obstructive shock allowed differentiation of adverse outcome risk between patients with shock (21.4%) and persistent hypotension (9.5%), resulting in a net reclassification improvement (0.24 ± 0.08; P = 0.002).ConclusionThe revised ESC 2019 guidelines definition of high-risk PE stratifies subgroups at different risk of in-hospital adverse outcomes and all-cause mortality. Risk prediction can be improved by using an optimised venous lactate cut-off value to diagnose obstructive shock, which might help to better assess the risk-to-benefit ratio of systemic thrombolysis in different subgroups of high-risk patients.

Massive pulmonary embolism presenting with hemoptysis and S1Q3T3 ECG findings

BackgroundVenous thromboembolism clinically presenting with a deep vein thrombosis or pulmonary embolism is among the most commonly seen cardiovascular syndromes. The aim of this case presentation is to emphasise the typical electrocardiographic findings that are detected with massive pulmonary embolism along with the electrocardiographic S1Q3 and S1Q3T3 accompanied by T negativity at the D3 derivation based on prevalent T negativity.Case presentationWe present the case of an adult male who presented with a massive pulmonary embolism that was associated with tachycardia, haemoptysis and typical S1Q3T3 electrocardiographic findings. Tomographic findings showed filling defects in the two main pulmonary artery lumens, which were found to be compatible with a massive embolism. Intravenous heparin was injected (5000 IU), and low molecule weight heparin (LMWH) treatment was initiated. After two days of observation and treatment in the coronary intensive care unit, the patient was discharged for outpatient care.DiscussionMassive pulmonary embolism is an urgent life-threatening clinical situation that is frequently confused with acute ST elevation myocardial infarction. The definitive diagnosis of massive pulmonary embolism was made with a computed tomography pulmonary angiogram. Electrocardiographic findings and hypoxic hypercarbia in the blood gas analysis are typical. Early diagnosis with laboratory and imaging investigations is vital in the treatment and prognosis of pulmonary embolism.ConclusionsVentricular overload signs accompanied by ST segment elevation in electrocardiography and S1Q3 and prevalent T negativity are crucial features in terms of distinguishing between pulmonary embolism and myocardial infarction and selecting effective treatments for patients admitted to the emergency department.

Presentation, Management and Outcomes of Pediatric Pulmonary Embolus: A Retrospective Review.

To review the presentation, management, and outcomes of pediatric pulmonary embolism (PE) patients treated at a single institution over 10 years to determine whether laboratory findings and clinical presentation predict disease severity. We performed a retrospective chart review of patients treated for PE in a 14-bed pediatric intensive care unit from January 1, 2008, to December 31, 2018. Associations between clot burden and disease severity, clinical risk factors (body mass index, recent hospitalization, estrogen use), clinical presentation (heart rate, oxygen saturation), and laboratory values (white blood cell count, D-Dimer, troponin, proBNP) were performed using Student t test, χ2 tests, and 1-way analysis of variance. Patients were risk stratified by American Heart Association guidelines. Eighteen (72%) patients (girls) were treated for PE. Common risk factors included recent hospitalization (67%) and oral contraceptives (62%). Risk factors, clinical presentation (including hypoxemia and tachypnea), and laboratory studies did not correlate with disease severity or clot burden. Electrocardiogram and radiographic findings were non-specific. Computer tomography pulmonary angiography (CTPA) was required to diagnose 94%. Sixteen received unfractionated heparin, and 5 required additional intervention. Risk factors, clinical features, and laboratory studies did not predict who required intervention. Of 18 pediatric patients treated for PE at a single institution over 10 years, vital signs and laboratory data did not predict disease severity or clot burden, and CTPA was required for diagnosis in all but 1. Emergency room providers must have a high index of suspicion for diagnosis and cannot be reassured by normal electrocardiogram or plain film findings. At a time when pediatric providers are under pressure to minimize unnecessary radiation exposure, this lack of correlation of clinical presentation and laboratory findings highlights the importance of considering CTPA when PE is suspected.

Massive pulmonary embolism presenting with acute hemiparesis and aphasia: a case report of paradoxical embolism documented with transthoracic echocardiography

Massive pulmonary embolism presenting with acute hemiparesis and aphasia: a case report of paradoxical embolism documented with transthoracic echocardiography

SIMULTANEOUS PRESENTATION OF A PATIENT WITH ACUTE CORONARY SYNDROME, ACUTE LIMB ISCHEMIA AND DEEP VENOUS THROMBOSIS COMPLICATED BY PULMONARY EMBOLISM IN EMERGENCY ROOM: A CASE REPORT

Deep Venous Thrombosis (DVT) develops in chronic diseases and prolonged immobilization. DVT is usually com­plicated by pulmonary embolism (PE). Common presentation of pulmonary embolism is chest pain and dyspnea. Similar is the presentation in patients with acute coronary syndrome (ACS). However, a patient who present with ACS and acute limb Ischemia and later on develop DVT complicated by PE simultaneously, is a very rare phenom­enon. Such coexistence developed by chance or a common pathophysiological process, remains unclear. Again, it is very difficult to ascertain, what was the initial event and what was the sequence of events. Management of such patients is also challenging, as priority of treatment has to be decided. ACS and acute limb ischemia, if not intervened well on time, usually end up in acute myocardial infarction or death and gangrenous limb or amputa­tion, respectively. We received a patient in emergency room with ACS, acute limb ischemia, DVT and PE. This case report was a diagnostic and management dilemma. Such a coincidence is very unusual and therefore this case is presented.

Acute provoked pulmonary embolism masquerading as inferior wall myocardial infarction with right ventricular infarction

We present an extreme rare case of acute pulmonary embolism in an 83-year-old male presenting as acute inferior wall ST-elevated myocardial infarction with right ventricular infarction (RVMI) in electrocardiogram (ECG). Acute pulmonary embolism presenting as acute inferior wall ST-elevation myocardial infarction with RVMI has not been described in the world literature so far. Our case is unique and first to describe the presentation of acute pulmonary embolism in the form of inferior wall ST-elevated myocardial infarction with evidence of RVMI in the ECG. It is of utmost important for the treating cardiologist and critical care physician to differentiate the same as treatment modalities of both conditions varies markedly and wrong therapeutic measures can land up in a catastrophe.

When pulmonary embolism mimics pneumonia: An interesting case report

The classic presentation of pulmonary embolism is rather uncommon. The lack of pathognomonic signs and symptoms makes the diagnosis of PE difficult. Here, we report a patient presented with symptoms suggestive of pneumonia and ultimately diagnosed as PE. A 75 years old male patient with no known co-morbidity, presented with of breathlessness for 1 week, cough for one week, productive in type, with scanty sputum, chest pain since one week, sharp, aggravated on coughing. His respiratory system examination revealed increased VF/VR in right mammary and left infrascapular areas, equal air entry with normal vesicular breath sounds, crepitations in the right mammary and left infrascapular areas. He was initially treated as pneumonia but did not respond. His chest X-ray PA view showed probable mass lesion in the right para cardiac region, ECG– sinus tachycardia with right axis deviation and RV strain pattern. CECT Thorax- Intraluminal thrombus in Rt and Lt pulmonary artery consistent with acute pulmonary thromboembolism.The patient was lysed with Inj. Streptokinase and subsequently improved over the next 6 days. Whilst established criteria aid in ruling in or out the diagnosis in a setting, the gestalt of a clinician is the most appropriate defence against a missed diagnosis especially in settings of confounded presentation. Therefore, until conclusively proven with the help of imaging and lab-work, PE should be a diagnosis that needs be considered in any case of atypical pneumonia who is not responding to first line therapies.

Systemic thrombolysis and anticoagulation improved biomarker measurements in massive-like pulmonary embolism and severe COVID-19 pneumonia: a case report.

BackgroundFrom asymptomatic patients to severe acute respiratory distress syndrome, COVID-19 has a wide range of clinical presentations, and venous thromboembolism has emerged as a critical and frequent complication.Case summaryWe present a case of a 69-year-old man with a clinical presentation of massive-like pulmonary embolism (PE) overlapping with severe COVID-19 pneumonia. The diagnosis was made based on hypotension, severe oxygen desaturation (33%), and right ventricular dysfunction (RVD). We used alteplase and low-molecular-weight heparin, obtaining immediate clinical improvement. Also, we identified an extremely elevated D-dimer (31.2 mcg/mL), and computed tomography pulmonary angiography (CTPA) revealed an unexpected low thrombus burden and a crazy-paving pattern. Considering this, we decided to discontinue the alteplase. Therefore, the mechanisms of pulmonary hypertension and RVD could be multifactorial. Despite the patient’s respiratory status worsening and ongoing mechanical ventilation, biomarkers kept lowering to normal ranges. It appears a favourable outcome was related to early PE diagnosis and a multimodal therapeutic approach.DiscussionPhysicians in the ER should be warned about extremely high D-dimer measurements and severe oxygen desaturation as possible markers of severe COVID-19 pneumonia in patients with high-clinical suspicion of PE. Although ESC guidelines recommend immediate reperfusion in cardiogenic shock secondary to PE, we suggest initial CTPA in patients with high-clinical suspicion of severe COVID-19.

Abstract 13452: Sex Differences in Presentation, Management, and Outcomes Among Patients Hospitalized With Acute Pulmonary Embolism

Introduction: The presence of gender disparities in cardiovascular disease has been well-described, but there is a paucity of data regarding the impact of gender on the presentation, management and outcomes of acute pulmonary embolism (PE). Hypothesis: We hypothesized that there are no gender-based differences in PE management or outcomes. Methods: We identified all patients admitted to our institution with acute PE from 8/1/2012-7/1/2018. We stratified presenting characteristics, management and outcomes between women and men. Outcomes included major bleeding, survival, 90-day readmission, and 90-day recurrent venous thromboembolism (VTE). Inverse probability of treatment weighting was used to evaluate the independent association between sex and in-hospital and short-term outcomes. Results: The study included 2031 patients with PE, 53.2% of whom were women. Women had a higher mean age (63.8 years vs 62.3 years, P=0.04). PE severity was similar between women and men (massive: 4.9% vs 3.6%; submassive: 43.9% vs 41.8%; P=0.19), but women were more likely to present with dyspnea (59.8% vs 52.0%, P&lt;0.001) and had higher median NT-pro-BNP levels (605 pg/mL [IQR 143-2582] vs 319 pg/mL [IQR 82-1576], P&lt;0.001). Although the comorbidity burden was similar, women were less likely to have a history of PE (19.3% vs 24.2%, P=0.01), smoking (43.1% vs 53.3%, P&lt;0.001), or myocardial infarction (6.6% vs 9.7%, P=0.01). In unadjusted analyses, women were less likely to survive to discharge (92.4% vs 94.7%, P=0.04), but after adjustment, there was no gender-based survival difference. There were also no gender differences in PE-related diagnostic studies, use of advanced therapies, or other short-term outcomes, before and after adjustment (p&gt;0.05 for all) (Fig 1). Conclusions: In this large PE cohort from a tertiary care institution, women had different comorbidity profiles and PE presentations than men. Despite this, there were no gender disparities in PE management or outcomes.

Management of a huge right atrial thrombus in a patient with multiple comorbidities

BackgroundFloating right heart thrombi (RHT) represent an underdiagnosed, potentially hazardous, and to some extent rare phenomenon in patients presenting with acute pulmonary embolism (APE). Emergent treatment is usually required for such a condition.Case presentationA 19-year-old young lady presented with progressive shortness of breath, marked renal impairment, thrombocytopenia, and a highly oscillating huge right atrial mass. After she was admitted to the intensive care unit, she arrested in asystole and was resuscitated, and her electrocardiogram (ECG) showed evidence of acute anterior myocardial infarction. Urgent cardiac surgery to remove the right atrial mass was proposed by the heart team as the best option of management. Surgery was emergently performed with extra-corporeal membrane oxygenator (ECMO) as a support. Following surgery, mechanical support and vasopressors were successfully weaned and the patient achieved a good recovery.ConclusionsA pulmonary embolism response team (PERT) approach should always be considered where a multidisciplinary team involving a cardiologist, radiologist, cardio-thoracic surgeon, radiologist, and intensivist shall determine the management strategy for a challenging presentation of a massive pulmonary embolism or floating right heart thrombi causing the hemodynamically unstable clinical condition.

A DIAGNOSTIC DILEMMA: NORMAL D-DIMER IN A PATIENT WITH EXTENSIVE PULMONARY EMBOLISM

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The presentation of pulmonary embolism (PE) is very non-specific and carries a significant morbidity and mortality. Typically, D-dimer assay has a very high sensitivity and a negative predictive value of 99-100% in both low and moderate risk groups. We present a unique case of diagnosing extensive PE with deep vein thrombosis (DVT) in presence of a normal D-dimer. CASE PRESENTATION: A 69-year-old female with significant history of hypertension and diabetes presented with dry cough and worsening of dyspnea on exertion for four days. Patient denied chest pain, palpitations, fever, chills, diaphoresis, leg pain or swelling. Vitals showed a T 98.6, BP 112/64 mmHg, HR 56, RR 16, oxygen saturation of 90% on 3LPM of nasal canula. Physical exam, especially the pulmonary exam, was largely unremarkable. No swelling or pain in the lower extremities was noted. Laboratory findings including the metabolic panel, blood count, and a set of troponins were within normal limits. ECG showed a normal sinus rhythm, and a follow-up chest radiograph and a non-contrast CT scan of chest did not demonstrate any significant findings. Acute PE was ruled out since the D-dimer assay was normal and the pretest probability was low-moderate. Preliminary diagnosis of pulmonary hypertension was suspected and worked up. An echocardiogram showed severe pulmonary hypertension with elevated right ventricular systolic pressure in the setting of a normal LV ejection fraction. A ventilation perfusion scan was subsequently done to evaluate for CTEPH, and was overwhelmingly positive with a high probability of PE. A CT angiogram revealed extensive bilateral central and segmental PE. Doppler ultrasound of lower extremities revealed an acute non-occlusive DVT involving the left popliteal vein. Patient was subsequently started on anti-coagulants and the supplemental oxygen was continued prior to safe discharge. DISCUSSION: D-dimer assay is a highly sensitive test used in the evaluation of PE. It is a measure of monoclonal antibody to D-Dimer produced during the process of fibrinolysis. D-dimer has a half-life of 4-6 hours and stays elevated for about seven days. Once the clot organization and adherence begins, levels of D-dimer drop. As such, D-dimer levels correlate with the presence of fibrin clots. The assay can be falsely negative if the specimen is collected very early or later than 7 days of clot formation. Regardless, a negative assay should be able to safely rule out a large PE in low and moderate risk patients. A low d-dimer assay on presentation in light of an extensive PE/DVT makes our case unique. CONCLUSIONS: D-dimer assay usually provides excellent diagnostic yield while ruling out a PE/DVT. However, it remains prudent to consider the overall clinical presentation and go through a step by step approach to not miss a disease with a fatal potential such as a PE in our case. Reference #1: Dagkiran H, Atas R, Tomic I, Plachtzik C, Geisler T, Gawaz MP, Oberhoff M, Anger T. Severe Pulmonary Embolism with Negative D-Dimer-Testing. Journal of Cardiology and Therapy 2015; 2(1): 265-268 Available from: URL: http://www.ghrnet.org/index.php/jct/article/view/1033 Reference #2: Gupta RT, Kakarla RK, Kirshenbaum KJ, Tapson VF. D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. AJR Am J Roentgenol. 2009;193(2):425-430 Reference #3: Le Gal G, Righini M, Roy P, et al. Value of D-Dimer Testing for the Exclusion of Pulmonary Embolism in Patients With Previous Venous Thromboembolism. Arch Intern Med. 2006;166(2):176 -180. doi:http://dx.doi.org/10.1001/archinte.166.2.176 DISCLOSURES: No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Kinjal Patel, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response No relevant relationships by Krunal Trivedi, source=Web Response

EARLY MANAGEMENT OF ACUTE BILATERAL PULMONARY EMBOLISM IN A PATIENT PRESENTING WITH RECURRENT SYNCOPE

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Recurrent syncope is a rare presentation of pulmonary embolism that can be associated with quick deterioration and poor prognosis. Early recognition and intervention are critical to prevent early morbidity and mortality. We present this case to emphasize the importance of early thrombolytic therapy in patients presenting with syncope-associated pulmonary embolism. CASE PRESENTATION: A 43 year-old female initially presented to the emergency department with shortness of breath and syncope. She has a history of superficial DVTs, nicotine dependency, and morbid obesity. On presentation, she was alert and oriented with normal neurological findings. She had an elevated heart rate of over 120 with an oxygen saturation of 90% on 2L NC and was hemodynamically stable. Her labs were significant for leukocytosis, an elevated D-Dimer of 2.85ug/mL, BNP: 17400 pg/mL, and an initial troponin of 0.063ng/mL. An emergent chest-CT was performed which revealed large bilateral pulmonary emboli. The patient was subsequently started on full-dose Lovenox and sent to the progressive care unit for further evaluation and management. Overnight, the patient was noted to have an episode of syncope that was associated with cyanosis, tremors, and diaphoresis. At the time, her blood pressure was stable at 130/80 as she remained mildly lethargic. As the patient did not meet formal indications for systemic tissue plasminogen activator (tPA), she was immediately transferred to the ICU for further evaluation and closer monitoring of her symptoms. During the day, an echocardiogram was performed which revealed a severely dilated right atrium and ventricle with a right ventricular systolic pressure of 66.2 mmHg. The patient had fleeting episodes of bradycardia and hypotension with a noted drop of over 40 mmHg in her systolic pressure on slight movements. Given her rapid decompensation, the patient was immediately transferred to a facility capable of performing intervention catheter-directed thrombolysis for treatment. Following the transfer, the patient was pronounced deceased following complications relating to her condition. DISCUSSION: Syncope associated pulmonary embolism can be fatally attributed due to rapidly decreasing cardiac output if not treated emergently as seen in this critically ill patient. CONCLUSIONS: Syncope-associated pulmonary embolism is a medical emergency that can be associated with poor prognosis and rapid decompensation. With a 90-day mortality rate of 17.4%[1], pulmonary embolism requires heightened clinical suspicion and immediate therapy to prevent fatal pulmonary and cardiac complications. While current guidelines indicate that systemic and catheter-directed thrombolysis are reserved for those with hemodynamic instability, those presenting with recurrent syncope may predict rapid decompensation and may also benefit from early thrombolytic therapy or mechanical thrombectomy if contraindications exist. Reference #1: Altınsoy, Bülent, et al. “Syncope as a Presentation of Acute Pulmonary Embolism.” Therapeutics and Clinical Risk Management, Dove Medical Press, 27 June 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4930221/. DISCLOSURES: No relevant relationships by Khalid Sawalha, source=Web Response

Impact of cardiovascular risk factors on the clinical presentation and survival of pulmonary embolism without identifiable risk factor.

BackgroundThe nature of pulmonary embolism (PE) without identifiable risk factor (IRF) remains unclear. The objective of this study is to investigate the potential relationship between cardiovascular risk factors (CVRFs) and PE without IRF (unprovoked) and assess their role as markers of disease severity and prognosis.MethodsA case-control study was performed of patients with PE admitted to our hospital [2010–2019]. Subjects with PE without IRF were included in the cohort of cases, whereas patients with PE with IRF were allocated to the control group. Variables of interest included age, active smoking, obesity, and diagnosis of arterial hypertension, dyslipidemia or diabetes mellitus.ResultsA total of 1,166 patients were included in the study, of whom 64.2% had PE without IRF. The risk for PE without IRF increased with age [odds ratio (OR): 2.68; 95% confidence interval (CI): 1.95–3.68], arterial hypertension (OR: 1.63; 95% CI: 1.27–2.07), and dyslipidemia (OR: 1.63; 95% CI: 1.24–2.15). The risk for PE without IRF was higher as the number of CVRF increased, being 3.99 (95% CI: 2.02–7.90) for subjects with ≥3 CVRF. The percentage of high-risk unprovoked PE increased significantly as the number of CVRF rose [0.6% for no CVRF; 23.8% for a CRF, P<0.001 (OR: 9.92; 95% CI: 2.82–34.9); 37.5% for two CRFs, P<0.001 (OR: 14.8; 95% CI: 4.25–51.85); and 38.1% for ≥3, P<0.001 (OR: 14.1; 95% CI: 4.06–49.4)]. No significant differences were observed in 1-month survival between cases and controls, whereas differences in 24-month survival reached significance.ConclusionsA relationship was observed between CVRF and PE without IRF, as the risk for unprovoked PE increased with the number of CVRF. In addition, the number of CVRF was associated with PE without IRF severity, but not with prognosis.

Pulmonary Embolism Presenting as an Anterior ST-elevation Myocardial Infarction: A Case Report.

IntroductionWhile the electrocardiogram (ECG) for pulmonary embolism typically shows tachycardia or evidence of right heart strain, it can demonstrate ischemic changes similar to acute coronary syndrome.Case ReportThe patient in this case presented with syncope, chest pain, and an ECG showing an anterior acute myocardial infarction (AMI) without evidence of right heart strain. His cardiac catheterization showed no coronary artery occlusions, but some signs of pulmonary embolism (PE), which was confirmed on computed tomography angiography of the chest.ConclusionThis case demonstrates that PE should be high on the differential for AMI and describes an uncommonly encountered mimic for classic ST-elevation myocardial infarction ECG changes. Further diagnostics to confirm the diagnosis should be obtained when indicated.

Case Report: A Near Miss of Pulmonary Embolism in a Division 1 Collegiate Basketball Player.

IntroductionThe clinical presentation of pulmonary embolism (PE) is often associated with classic vital instability such as tachycardia, hypoxia, and tachypnea. This critical diagnosis is often less likely if a patient is negative by Pulmonary Embolism Rule-Out Criteria (PERC) standards with a low pre-test probability of disease. Caution must be used when evaluating elite athletes with the PERC rule due to low resting heart rate and certain risk factors, which are inherent to athletics.Case ReportWe report the case of a 20-year-old male Division 1 collegiate athlete with pleuritic chest pain diagnosed with PE despite being PERC negative. His presenting heart rate (HR) of 79 beats per minute was correctly determined to be tachycardic relative to his resting HR of 47–60 beats per minute. Despite his PERC negative status, PE was found after an elevated D-dimer and subsequent computed tomography angiography.ConclusionSpecial consideration should be used when evaluating elite athletes for PE, as their resting physiology may differ from the general population. Additionally, certain risk factors for thromboembolic disease are inherent in competitive athletics and should be considered during an initial risk assessment. The presented patient was successfully treated with oral anticoagulation for three months and was able to return to play.

The Positive Rate of Pulmonary Embolism by CT Pulmonary Angiography Is High in an Emergency Department, Even in Low-Risk or Young Patients

Objective: The clinical presentation of pulmonary embolism (PE) can be various and misleading. We analyzed patients with suspicion of PE and subsequently performed computed tomography pulmonary angiography (CTPA) in an emergency department of Internal Medicine, focusing on patient groups in which PE might be underestimated in the emergency setting, such as young patients and patients with low clinical probability. Material and Methods: In 2016 and 2017, all patients receiving a CTPA for investigation of PE were retrospectively evaluated for clinical parameters (age, symptoms, and vital parameters) and D-dimers. The Wells score was calculated. Results: CTPA was performed in 323 patients (158 female and 165 male; mean age 62 years). The leading symptoms for admission were dyspnea or chest pain; 62% showed intermediate or high risk for PE, calculated by applying the Wells score. In 123 (38%) of all patients, a PE was proved and pathologic age-adjusted D-dimers were found in 97.6%. Thirty of 121 (25%) patients with low risk according to Wells score had a PE. Deep vein thrombosis was verified in 67/123 (55%) patients; 43% (15/35) of all suspicions for PE in patients <40 years were positive with 4/15 (26%), showing a central PE. Younger patients (<40 years) with PE presented more often with tachycardia or tachypnea and chest pain or dyspnea than elderly patients with PE. Conclusion: CTPA frequently proves a PE in patients with suspicion of PE in an emergency department of Internal Medicine. If PE is suspected and CTPA performed accordingly, the presence of PE is quite common even in low-risk patient groups (Wells score) or in young patients <40 years with chest pain or dyspnea.

Successful Treatment of Pulmonary Embolus Secondary to Diabetic Ketoacidosis with Tissue Plasminogen Activator

A 75-year-old woman with a history of Type 2 Diabetes mellitus attended triage with complaints of nausea, occasional vomit, pain in epigastrium and some vague heaviness in breathing of 4-5 days duration. On her physical examination she had mild tachypnea, peripheral capillary oxygen saturation (SpO2) 92% on room air, and high blood glucose and ketones respectively. She was evaluated and diagnosed to have bilateral submassive pulmonary Thromboemboli.&#x0D; She was managed with fibrinolytic treatment, Heparin, and supportive treatment along with management of Diabetic Ketoacidosis (DKA). Etiological examinations did not reveal any underlying cause. The contribution of diabetes and its acute complication, DKA, to the development of pulmonary thromboembolism is controversial and is discussed. This case with the presentation of sub-massive pulmonary embolism in a patient of DKA with no underlying cause identified is being reported owing to its rareness.

Rare Presentation of Pulmonary Embolism Associated with PCP in a 28-Year-Old Man who was not known to be infected with HIV Before

Introduction Human Immunodeficiency Viruses (HIV) commonly presented with acute seroconversion symptoms or opportunistic infections from immunosuppression, but first presentation of HIV with pulmonary embolism associated with active Pneumocystis pneumonia (PCP) is very rare. Case presentation A 28-year-old man presented with history of fever and cough associated with dyspnoea over 8 weeks and gradually worsen till maximised 2 week prior to admission. he did not improved inspite of antibiotics for suspected pneumonia. Found to be HIV positive with opportunistic infection. Computed Tomography Pulmonary Angiogram (CTPA) confirmed the presence of pulmonary embolism. He was treated successfully with anticoagulants, steroids, and antibiotics . discharged on base of clinical and radiological improvement. Conclusion Pulmonary embolism can be the first presentation of a newly diagnosed with HIV patient. The similar features of both viral pneumonia and subacute pulmonary embolism can lead to delay diagnosis, especially in the era of covid-19 pandemic infection