Pulmonary Embolism In Children Research Articles

MDCT Pulmonary Angiography Evaluation of Pulmonary Embolism in Children

The purpose of our study was to determine the prevalence and anatomic distribution of pulmonary embolism (PE) in a group of consecutive pediatric patients with clinically suspected PE using MDCT pulmonary angiography (pulmonary CTA). We used our hospital information system to retrospectively identify all consecutive pediatric patients (< 18 years of age) with clinically suspected PE who underwent pulmonary CTA from July 2004 to August 2007. Two experienced pediatric radiologists retrospectively reviewed by consensus a series of 98 consecutive pulmonary CTA studies. Each examination was reviewed for the ability to visualize pulmonary arteries and the presence of PE. For positive cases, the level of involvement was classified as central, lobar, segmental, or subsegmental. Lobar location was also recorded using standard nomenclature. Pulmonary CTA results were compared with the results of lower extremity ultrasound studies in the subset of patients who underwent both procedures. The study population consisted of 84 children who underwent a total of 98 pulmonary CTA studies. All pulmonary CTA studies were technically successful in visualizing arteries to the level of segmental pulmonary arteries, but the evaluation of subsegmental pulmonary arteries was limited in 78 (80%) examinations. Thirteen (15.5%) of 84 children were found to have PE on pulmonary CTA. PE was localized in the lobar pulmonary artery in 12 (39%), the segmental pulmonary artery in 11 (35%), the subsegmental pulmonary artery in five (16%), and the main or central pulmonary artery in three (10%) patients. PE was distributed in the right lower lobe in 12 (37%), the left lower lobe in eight (24%), the right upper lobe in five (15%), the right middle lobe in four (12%), and the left upper lobe in four (12%) patients. Ten of 13 patients with PE underwent lower extremity Doppler ultrasound, of whom one (10%) was positive for deep venous thrombosis. The prevalence of PE may be more common among pediatric patients than previously reported and has a similar distribution to that in adult patients.

Snippets in surgical pathology

This section will feature features synopses of pertinent practical publications that appear in Pathology journals in the respective sub-specialties. The summaries are mere guidelines and personal opinions of the two...

Clinical features and outcome of pulmonary embolism in children

Pulmonary embolism (PE) is rare in childhood but evidence suggests it is under-recognised. Children diagnosed with PE at a large tertiary centre over an 8-year period were retrospectively reviewed. Fifty-six children with radiologically proven PE were identified, 31 males and 25 females, median age 12 years. Eighty-four per cent had symptoms of PE. Risk factors for thromboembolism were present in 54 patients (96.4%); most commonly immobility (58.9%), central venous line (35.7%) and recent surgery (28.6%). Investigation revealed a thrombophilic abnormality in 14/40 patients (35%). Concurrent deep vein thrombosis was confirmed in 31 patients (55.4%), predominantly lower limb. D dimer was elevated at presentation in 26/30 patients (86.7%). Eight patients underwent systemic thrombolysis. An inferior vena cava filter was placed in five patients. Therapy was complicated by major haemorrhage in 12 patients (21.4%). The majority (82.1%) had complete or partial resolution of PE following a median of 3 months anticoagulation. Seven patients had a recurrent thromboembolic event and 12 patients died (mortality 21.4%); five due to thromboembolism (8.9%) and two due to haemorrhage. Risk factors for PE in children are distinct from adults and morbidity and mortality is significant. Multicentre prospective studies are required to determine optimal treatment and long-term outcome of childhood PE.

Pulmonary embolism—experience at a single children's hospital

Introduction Pulmonary embolism in children is a rare, potentially life threatening condition. The clinical characteristics of pediatric pulmonary embolism have not been well studied and the exact incidence in children is not known. We report a case series of fourteen patients with pulmonary embolism and describe their clinical characteristics. Materials and methods Inpatient and outpatient clinic charts of patients with proven pulmonary embolism (PE) followed at the Hemostasis and Thrombosis Center at Children's Hospital of Michigan were reviewed for relevant clinical and laboratory information. Results All patients with PE were symptomatic but accurate diagnosis of PE was often delayed in the outpatient setting. Screening testing with D-dimer was normal in 40% of patients. Acquired risk factors and lower extremity clots were more common in patients analyzed. Treatment regimens differed but most patients had resolution of pulmonary emboli on follow-up. Conclusions A high index of suspicion is needed for the diagnosis of pediatric PE. D-Dimer may be normal in some children with PE. Pediatric multicenter trials are needed to evaluate clinical characteristics, risk factors, long-term outcome and effects of PE on pulmonary and cardiac function.

Calcified pulmonary thromboembolism in a child with sickle cell disease: value of multidetector CT in patients with acute chest syndrome

The incidence of pulmonary embolism in children is not clearly known, but is believed to be low. Risk factors for pulmonary thromboembolism include central venous catheter, malignancy, surgery, infection, trauma, and congenital hypercoagulable disorders. Children with sickle cell disease are prothrombotic and are at an increased risk of thromboembolism. The incidence of this event is unknown because these children are often not thoroughly imaged. We report here a case of a calcified pulmonary thromboembolism in a child with sickle cell disease and emphasize the use of multidetector CT in detection of pulmonary thromboembolism in children with sickle cell disease.

Pulmonary thromboembolism in children

Pulmonary thromboembolism (PTE) is uncommonly diagnosed in the pediatric patient, and indeed often only discovered on autopsy. The incidence of pediatric PTE depends upon the associated underlying disease, diagnostic tests used, and index of suspicion. Multiple risk factors can be found including: peripartum asphyxia, dyspnea, haemoptysis, chest pain, dehydration, septicemia, central venous lines (CVLs), trauma, surgery, ongoing hemolysis, vascular lesions, malignancy, renal disease, foreign bodies or, uncommonly, intracranial venous sinus thrombosis, burns, or nonbacterial thrombotic endocarditis. Other types of embolism can occur uncommonly in childhood and need to be recognized, as the required treatment will vary. These include pulmonary cytolytic thrombi, foreign bodies, tumor and septic emboli, and post-traumatic fat emboli. No single noninvasive test for pulmonary embolism is both sensitive and specific. A combination of diagnostic procedures must be used to identify suspect or confirmed cases of PTE. This article reviews the risk factors, clinical presentation and treatment of pulmonary embolism in children. It also highlights the current diagnostic tools and protocols used to evaluate pulmonary embolism in pediatric patients.

Pulmonary Embolism in Children.

Pulmonary embolism (PE) is rare in children and optimal methods for diagnosis, management and treatment for children with PE are unknown. We report a case series of 13 patients (pts) with PE managed at the Thrombosis Treatment Center at Children's Hospital of Michigan in the last 48 months and discuss their clinical characteristics.Demographics:13 pts (7 males, 6 females; 6 African - American, 7 Caucasian) were followed for a duration of 1– 43 months (mean 16 months). Average age at presentation was 16.3 years (range 9–29 years; 11 pts were less than 18 years of age). One patient had a previous documented PE but had been lost to follow-up.Average time to diagnosis of PE was 7.7 days (1–21 days) after onset of first symptom. 3 pts diagnosed at the onset of symptoms were in the hospital at the time of the event. 1 patient was diagnosed almost a year after onset of symptoms. 8 patients (61.5%) received treatment for other respiratory illness prior to the accurate diagnosis of PE. All pts were symptomatic and had chest pain (69 %) or dyspnea on exertion (76.9%).Diagnostic Studies:Chest radiography was performed in 10 pts and was abnormal in 7 (70 %). D-Dimer was normal in 30 % of patients. All pts were diagnosed with a spiral CT. Additional clots were present in 10 pts (1 upper extremity, 1 cortical sinus, 2 superior vena caval, 6 lower extremity)and were diagnosed by ultrasonography (2), venography (5), echocardiography (2) and magnetic resonance venography (1).Risk factors:Antithrombin III, protein C and protein S were normal in all patients.1 patient was heterozygous for prothrombin G20210A mutation. None of the pts had Factor V Leiden. Six (46%) pts were heterozygous for the MTHFR C677T mutation but only one had an elevated homocysteine level.Seven (53.8 %) patients were obese. Other risk factors were systemic lupus erythematosus in 2 (15.4 %), ventriculo-atrial shunt in 3 (23.1%), inflammatory bowel disease (IBD) in 2 (23.1%) and immobilization in 4 (30.8 %) patients. No identifiable risk factor was found in one patient. A central venous line was present in one pt (7.7%). Anticardiolipin antibodies were elevated in 23.1 % and lupus anticoagulant was positive in 46.2 %Treatment:Pts received unfractionated heparin (76.9 %), catheter-directed thrombolysis (15.4%) or low molecular weight heparin (7.7 %) as initial treatment. 5 pts (38.4%) had undergone a recent (within 14 days) surgical procedure and could not receive thrombolytic therapy. 11 pts (84.6 %) received low molecular weight heparin (LMWH) and 2 (15.4%) received warfarin as follow-up treatment. 5 pts received therapy for a minimum of 12 months following the episode and none had a recurrence. 8 other pts are still on anticoagulation therapy (mean duration 4.75 months, range1–11 months) and have no recurrence. Therapy was well tolerated in pts treated with LMWH; 1 patient with IBD on warfarin had recurrent gastrointestinal bleeding necessitating blood transfusion.Summary:PE is often missed in children and should be included as a differential diagnosis in pts with chest pain or dyspnea on exertion. As diagnosis is delayed, a normal D-Dimer may not exclude the presence of PE in children. Acquired risk factors appear to play a major role in the pathogenesis of pediatric PE. As in adults, PE in children is often associated with lower extremity venous clots. Specific treatment protocols need to be developed for children with PE as most patients either cannot or do not receive thrombolyis.

Venous catheter thrombus formation and pulmonary embolism in children

Central venous catheter (CVC)-related thrombus formation has been increasingly recognized as a complication in adults and somewhat less frequently in children and neonates. However, the association of CVC thrombus and pulmonary embolism (PE) has rarely been reported in infants or children, and the few existing reports primarily involve chronic, indwelling CVCs such as Broviac or Hickman catheters. During an 18-month-period of autopsy review, we found that 5 of our pediatric intensive care unit patients had autopsy-proven CVC thrombus and pulmonary embolism. All of them had prolonged mechanical ventilation for respiratory failure and required insertion of one or more short-term, temporary CVCs during the course of routine critical care management. In retrospect, signs related to CVC thrombus were present in 4 patients (3 had positive blood cultures and 1 had persistent hypertension). PE was not diagnosed until autopsy in every case. The diagnosis may have been missed because the symptoms of PE are the same as those of severe lung disease. We, therefore, advocate a heightened suspicion of CVC thrombus formation and PE in critically ill children with respiratory failure and temporary CVCs and recommend early diagnostic ultrasound to confirm the diagnosis. Once a CVC thrombus is found, subsequent pulmonary deterioration may necessitate evaluation for acute PE.

Pulmonary Embolism in Children

Pulmonary embolism is an uncommon diagnosis in the pediatric patient, often discovered on autopsy. The mortality rate of untreated pulmonary embolism approaches 30%, and the best way to prevent death is by swift diagnosis and initiation of therapy. This article reviews the risk factors, clinical presentation, pathophysiology, diagnostic modalities, and treatment of pulmonary embolism in children.

Pulmonary embolism in children

The diagnosis of pulmonary embolism (PE) is seldom considered in the pediatric patient; however, pulmonary embolic phenomenon occur with a greater frequency than is generally recognized. Reports of all autopsies performed at the University of Michigan during the 25-yr period 1955 through 1979 were reviewed. All cases of pulmonary thromboembolism in infants and children ranging in age from 0 to 19 yr were studied; patients with emboli from fat or tumors and patients with primary pulmonary artery thrombosis were excluded. The records of 116 children with PE were evaluated. The sex distribution was equal and the average age was 8.0 yr. Age itself was not an independent risk factor for the development of PE. The primary disease processes of shunted hydrocephalus (15.2%), accidental trauma (8.4%), heart disease (4.5%), infection (4.4%), neoplasia (4.0%), and general medical illness (1.8%) were identified as significant risk factors for the development of pulmonary emboli. In the group with neoplasia, children with solid tumors (6.7%) were at an increased risk over the lymphomaleukemia group (2.6%) for the development of emboli. Children who had operation exclusive of the risk factors noted above (7.2%) were at an increased risk when compared to the nonoperative medical group (1.7%). Other risk factors including immobility, central venous catheterization, pre-existing hematologic disorders, and secondary infection were frequently seen. These factors, however, were not able to be studied epidemiologically. Venous thromboses were found in 40% of those children who had pulmonary emboli at the time of autopsy. Iliofemoral venous thrombosis was infrequently seen. The PE was deemed to be clinically important in 30% of the total series. In patients with clinically significant PE, only 50% had documented signs and symptoms of embolization and an antemortem diagnosis was considered in only one-third of these symptomatic patients. The total incidence of PE did not change over the 25-yr period, nor were there any significant trends in the associated risk factors. This study supports the concept that PE occurs in children with a greater frequency than is commonly recognized. Signs and symptoms of clinically significant pulmonary emboli occur in only 50% of the patients and even when the event presents clinically, it is an underdiagnosed entity. A heightened index of suspicion for PE in children is warranted. The diagnosis of pulmonary embolism (PE) is seldom considered in the pediatric patient; however, pulmonary embolic phenomenon occur with a greater frequency than is generally recognized. Reports of all autopsies performed at the University of Michigan during the 25-yr period 1955 through 1979 were reviewed. All cases of pulmonary thromboembolism in infants and children ranging in age from 0 to 19 yr were studied; patients with emboli from fat or tumors and patients with primary pulmonary artery thrombosis were excluded. The records of 116 children with PE were evaluated. The sex distribution was equal and the average age was 8.0 yr. Age itself was not an independent risk factor for the development of PE. The primary disease processes of shunted hydrocephalus (15.2%), accidental trauma (8.4%), heart disease (4.5%), infection (4.4%), neoplasia (4.0%), and general medical illness (1.8%) were identified as significant risk factors for the development of pulmonary emboli. In the group with neoplasia, children with solid tumors (6.7%) were at an increased risk over the lymphomaleukemia group (2.6%) for the development of emboli. Children who had operation exclusive of the risk factors noted above (7.2%) were at an increased risk when compared to the nonoperative medical group (1.7%). Other risk factors including immobility, central venous catheterization, pre-existing hematologic disorders, and secondary infection were frequently seen. These factors, however, were not able to be studied epidemiologically. Venous thromboses were found in 40% of those children who had pulmonary emboli at the time of autopsy. Iliofemoral venous thrombosis was infrequently seen. The PE was deemed to be clinically important in 30% of the total series. In patients with clinically significant PE, only 50% had documented signs and symptoms of embolization and an antemortem diagnosis was considered in only one-third of these symptomatic patients. The total incidence of PE did not change over the 25-yr period, nor were there any significant trends in the associated risk factors. This study supports the concept that PE occurs in children with a greater frequency than is commonly recognized. Signs and symptoms of clinically significant pulmonary emboli occur in only 50% of the patients and even when the event presents clinically, it is an underdiagnosed entity. A heightened index of suspicion for PE in children is warranted.

PULMONARY EMBOLISM IN CHILDREN.

Two cases of pulmonary embolism in children are described. The available literature on the subject is reviewed.

Pulmonary Embolism in Children

Pulmonary Embolism in Children

Pulmonary embolism in childhood

Summary 1. The literature concerning pulmonary embolism in children is reviewedand reference is made to twenty-nine previously reported cases. 2. A case of pulmonary embolism causing sudden death is reported in a9-year-old boy; emboli arose in thrombosed veins of the extremities. 3. The clinical and pathologic features of childhood pulmonary embolismare discussed; the rarity of peripheral thrombophlebitis in children is emphasized.