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ACUTE PULMONARY EMBOLISM

IN YOUNG : CASE REPORTS


SADEEP RANA

Pembimbing : dr. Arif Gunawan, Sp.PD, MARS.

Bernadetha Mayang
030.13.038
Definition
Pulmonary thromboembolic disease refers to the condition
in which blood clot(s) (thrombus or multiple thrombi)
migrate from the systemic circulation to the pulmonary
vasculature hemodynamic and oxygenation disturbance
Most of these blood clots arise from the deep veins of the
lower and upper extremities (deep venous thrombosis,
DVT).
Virchow first described the phenomena of embolism and
thrombosis in the mid-nineteenth century, and identified
three main factors (Virchows Triad): venous stasis,
hypercoagulability, and injury to the venous wall
(endothelium)
Introduction
Acute pulmonary embolism is a component of venous
thromboembolism (VTE), which may prove fatal if not
suspected and subsequently treated.
Incidence of pulmonary embolism is around 0.5-1 case
per 1000.
This has been estimated that 70% of proven post mortem
cases of pulmonary embolism are not even suspected
during the course of treatment. On the contrary, only 25-
30% of suspected cases turned out to be cases of
pulmonary embolism in post mortem studies.
Young patients are more likely to be mismanaged, as
suspicion in healthier young patient is very low.
Case Report 1
24-year-old young male patient, smoker, no known
comorbidity, presented to emergency department with
history of cough with streaky haemoptysis for 7 days,
fever, and breathlessness on exertion for 2 days.
Initial examination : RR 28/min, HR 120/min, BP 98/68
mmHg, SpO2 88%, temp 99,4oF (37,4oC), BMI 28kg/m2,
scattered wheeze on chest examination. No other
significant finding was noted
He was managed as a case of bronchial asthma and
started on intravenous antibiotics, nebulisation, and
steroid. The patient was shifted to intensive care unit
(ICU) for further management
Investigations : Hb
13,2 g%, total leukocyte
count (TLC)
12400/cumm, differential
leukocyte count (DLC)
P: 75%, L: 23%, E: 2%,
biochemistry was
normal, CXR PA view
normal, ECG sinus
tachycardia with right
axis deviation and right
ventricular strain pattern.
Cardiac markers were
normal
Follow up
The patient was initially continued on same management
and CXR, ECG was repeated next morning, revealing
similar findings. In the view of persistent breathlessness,
unremarkable chest finding on next day and persistent
CXR, ECG findings, pulmonary embolism were suspected.
He was started on low molecular weight heparin (LMWH)
in therapeutic dosage and further evaluated.
D-dimer came within normal limits, but in the view of
strong suspicion of pulmonary embolism, CT angiography
of thorax was done, which revealed pulmonary embolism
in bilateral main pulmonary artery (MPA) involving right
MPA more than left and segmental arteries involvement.
The patient had a history of crushing injury to left upper
limb few years back. Ultrasound of bilateral lower and
upper limb was normal.
2-D ECHO revealed moderate pulmonary artery
hypertension (PAH), dilated RV with McConnels sign
(decreased movement of RV free wall as compared to
apex)
The patient was continued on LMWH and supportive care.
Patient has improved gradually over a period of 1 week.
Case Report 2
26 years old young male patient, non smoker, no known
co-morbidity, presented to emergency department with
history of cough, haemoptysis, and breathlessness for 2
days and pleuritic chest pain left side for 1 day.
Initial examination : RR 36/min, HR 130/min, temp
100oF (37.8oC), SpO2 80%, BMI 30 kg/m2, chest and other
systemic examination yield no significant finding.
He was nebulised in emergency department and shifted to
ICU for further management by chest physician.
Investigations : Hb 14,2 g%, TLC 13400/cumm, DLC P :
78%, L: 19%, E: 2%, M: 1% , biohemistry was normal,
CXR PA view non homogenous pleural base opacity in
left upper zone and blunting of left costophrenic angle with
hyperlucent right hemithorax, ECG- RV strain pattern.
Cardiac markers were normal.
In the view of clinical findings and investigation, he was
suspected as a case of pulmonary embolism and started
on LMWH and further evaluated.
D-dimer was positive and CT angiography of thorax
revealed almost complete occlusion of left MPA and small
filling defect in right MPA and segmental filling defect in
left side.
2D-Echo revealed moderate PAH, dilated RV with
McConnels sign was present.
Patient was continued on LMWH, antibiotics and oxygen
therapy. Patient improved gradually over period of 3
weeks.
He was further evaluated at higher centre and serum
homocystein levels were raised and APLA antibodies
were positive.
The patient had normal 2D ECHO after 3 months of
treatment. He was continued on oral anticoagulant to
maintain International Normalised Ratio (INR) -2 to 3 and
under OPD follow-up.
Discussion
VTE encompasses pulmonary embolism, deep vein thrombosis
(79%) and superficial thrombophlebitis.
Thrombosis is caused by interaction of three Virchow factors,
that is, hypercoagulability, trauma, and stasis.
There are acquired and genetic risk factors responsible for
thromboembolism. Recent surgery, trauma, immobilisation,
pregnancy, and oral contraceptives are commonest acquired
factors which are most of the time, temporary in nature.
Other factors such as malignancies, for example hematological,
lung, and pancreatic and brain cancer pose greatest risk for
PTE, and cancer association is a predictor of increased mortality.
Smoking, obesity, atherosclerosis, hypertension and infection in
hospitalised patients are also common causes for PTE.
One patient had history of smoking and both of them were
obese. Smoking and obesity are independent acquired
risk factors for PE.
Cough, haemoptysis, breathlessness and chest pain were
common symptoms, which are common but not specific
for PE as well as sinus tachycardia and tachyapnea and
low blood pressure were found in both patients.
Classical triad of chest pain, haemoptysis and dyspnea is
present in less than 20% of cases.
Other tools to help in diagnosing PE : modified Wells
score, CXR, ECG, D-Dimer, CT angiography, 2-D ECHO
Treatment
Both patients were treated with LMWH and supportive
care. Before heparin, surgery was the only option with
100% mortality.
LMWH anticoagulants such as Enoxaparin, Dalteparin,
Tinzaparin, and Fondaparinux are preferred over
Unfractioned heparin (UFH), as chances of bleeding and
Heparin-Induced Thrombocytopenia (HIT) are very low.
UFH is preferred in patients with renal impairment, obese
(>150kg), low weight (<30kg) as monitoring with activated
partial thromboplastin time (aPTT) is easy and reversal
with protamine is available.
Conclusion
Acute pulmonary embolism in young adults is not very
uncommon.
A young adult presenting with acute onset of dyspnea,
pulmonary embolism should be kept a possibility, as most
of the time PE is not considered in differential diagnosis
while evaluating such patients in emergency.
Unlike infectious diseases, cardiac disorder or blood
disorder, no specific symptoms, signs, or investigation
reflect a disease process immediately.
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