Introduction:
Pulmonary embolism (PE) and deep vein thrombosis (DVT) are among the top three most common acute cardiovascular diseases. PE accounts for 5-15% of all in-hospital deaths. While PE most commonly presents following DVT, it can manifest in various other forms. Among the differential diagnoses of patients presenting to the emergency department with complaints of chest pain, dyspnea, hemoptysis, and syncope, PE should always be considered (1 – 3).
Here, we aim to present a case of PE detected in a patient presenting to the emergency department with complaints of hemoptysis and a history of DVT.
Case:
A 40-year-old male patient presented with a complaint of cough and bloody sputum that started the night before. The patient had a history of deep vein thrombosis (DVT) 40 days prior and also complained of chest pain and dizziness. He described coughing up approximately 400cc of blood in total. On arrival, the patient had a Glasgow Coma Scale (GCS) of 15, Blood Pressure (BP) of 90/60 mmHg, Heart Rate (HR) of 130/min, and oxygen saturation (SpO2) of 95% on room air. The electrocardiogram (ECG) revealed sinus tachycardia, widespread T-wave inversion in inferior and precordial leads, and S1Q3T3 pattern (Image 1). Arterial blood gas analysis showed an increased arterio-alveolar gradient (calculated: 58, expected for age: 14). Bedside ultrasound demonstrated McConnell’s sign in the apical four-chamber view and D-sign in the parasternal short-axis view (ımage 2). Intravenous contrast-enhanced pulmonary angiography revealed extensive thrombi in both main pulmonary arteries and segmental branches (Image 3). The patient was admitted to the Intensive Care Unit under the care of Pulmonology for further diagnosis and treatment.
Conclusion:
In patients with pulmonary embolism (PE), the presence of hypotension and shock is a fundamental indicator of high risk. Among clinical parameters, low systolic blood pressure, tachycardia, respiratory failure (low oxygen saturation and tachypnea), and syncope alone or in combination are unfavorable indicators for the short-term prognosis of PE (3).
The gold standard method for diagnosis is pulmonary angiography. In addition to this, some laboratory data, echocardiographic findings, and arterial blood gas (ABG) results can also be informative in establishing the diagnosis. EKG findings are utilized in the diagnosis of PE through scoring systems. According to this system, tachycardia, presence of incomplete or complete right bundle branch block, T-wave inversion in precordial leads, extent of T-wave inversion, presence of an S wave in lead I, a Q wave in lead III, and inverted T wave (S1Q3T3 pattern) in lead III are evaluated, and a predictive score for the diagnosis of PE is obtained accordingly. In our case, sinus tachycardia, widespread T-wave inversion in precordial leads, and S1Q3T3 pattern were observed on EKG. In a study, the average EKG score for patients with PE was found to be 4.7 (4, 5). The score in our case was 7.
On arterial blood gas (ABG), the presence of hypoxemia, hypocapnia, and respiratory alkalosis supports the diagnosis of PE. Additionally, the alveolar-arterial (A-a) gradient is an important parameter. In 14% of patients with PE, this gradient is found to be below 20 mmHg. A study has shown a linear correlation between the A-a gradient and mean pulmonary artery pressure (PAP) and lung perfusion defect, emphasizing that normal values do not exclude the diagnosis of PE (5, 6). In our case, an increased A-a gradient was observed, and respiratory alkalosis was seen on ABG.
In patients classified as low-intermediate risk for PE, attention should be paid to the detection of right ventricular dysfunction and myocardial damage due to acute pressure elevation for rapid and accurate prognosis assessment. Right ventricular dilation and the presence of elevated pulmonary artery pressure (PAP) on echocardiography (ECHO) are prognostic indicators in these patients (7). In our case, an increased PAP value was found.
Bedside ECHO findings are also significant in the diagnosis of PE. In a study, the sensitivity of septal flattening (D-sign in the parasternal short axis, also known as flattening of the interventricular septum) was 43%, with a specificity of 93%; McConnell’s sign (hypokinesia of the right ventricle with apical sparing) had a sensitivity of 35% and specificity of 99%. Overall, the sensitivity of ECHO in the diagnosis of PE was reported to be 92%, with a specificity of 64% (8).
In conclusion, it should be remembered that delayed diagnosis in cases of pulmonary embolism (PE) can lead to mortality rates of up to 30%, while timely diagnosis can reduce mortality to below 10%. The most important step in the diagnosis of PE is to have a suspicion. In the presence of suspicion, diagnosis should be confirmed with appropriate cases undergoing the gold standard diagnostic method, pulmonary CT angiography, in addition to laboratory, EKG, and bedside echocardiographic findings. Patients should be referred to the appropriate specialty for management.
References:
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Image 1. Sinus tachycardia on ECG with widespread T-wave inversion in inferior and precordial leads and S1Q3T3 pattern.
Image 2. McConnell’s sign on apical four-chamber cardiac ultrasound (USG) on the left, and D-sign on parasternal short-axis cardiac USG view on the right.
Image 3. Thrombi appearances (arrowheads) in both main pulmonary arteries and segmental branches on pulmonary CT angiography.
