A 67-year-old man presented to the emergency department
with five-day history of non-productive cough and progressive
dyspnea and a one-day history of right-sided pleuritic
pain.
According to the patient and his family statement, he
had been well until about one month earlier, when pain
developed in his right leg. Two day later, the pain resolved
and he didn't ask for any medical help except some Chinese
herb taken. However, non-productive cough and progressive
dyspnea were noted five days prior to this admission. He
visited to a local hospital for help and was diagnosed as
left-lower-lobe pneumonia and oral antibiotics had been
initiated for four days, while the condition didn't improve. At
the same time, right-sided pleuritic pain was noted for one
day. The patient, who resided in Taipei, had stopped smoking
18 years earlier an drank a moderate amount of alcohol since
his teenage. There was a history of type 2 diabetes mellitus,
for which he took an unknown oral medication. There was a
history of diabetes mellitus in several relatives, and a
sister had had three-later-term spontaneous abortions, without
further evaluation. The patient denied chest pain, fever,
chills, night sweats, weight loss, or any travel history in
recent half a year. There was no family history of stroke or
clotting disorders.
On examination, the
patient had marked respiratory difficulty, with a respiratory rate of
28 breaths per minute. The temperature was 36.4℃, the pulse
was 137. The blood pressure was 95/60 mmHg. His consciousness
was clear. No rash, patechiae, septic lesions, or
lymphadenopathy was detected. The lungs were clear. A grade
2/6 systolic murmur was present at left lower sternal border ;
a third heard sound was not heard. The liver was hard and
descended 4 to 5 cm below the right costal margin; the spleen
was no felt, and no fluid wave was detected. No bruit was
heard. The lower right leg was pale and cold below the calf,
and the right posterior tibial and dorsalis pedis pulses were
absent. The left foot was warm and the pulses were intact.
An arterial blood gas measurement
obtained which he was breathing room air showed a pH of 7.46,
a partial pressure of CO2 of 34mmHg, and a partial pressure of
O2 of 61 mmHg. A chest radiograph (Fig.1
) demonstrated a pleural-based,
wedge-shaped pulmonary infarction (Hampton’s hump) at left
lung base. There was a focal avascularity (Westermark’s sign)
in the right upper lung field. Transthoracic echocardiography
revealed right ventricular dilatation and hypokinesia, with
moderate tricuspid regurgitation and an estimated right
ventricular systolic pressure of 55 mmHg. Doppler studies of
legs showed proximal deep venous thrombosis in the right leg.
A ventilation-perfusion scan showed normal ventilation images
(not shown here) and loss of perfusion to the entire right
upper lobe as well as to the anterior, lateral, and medial
basal segments of left lower lobe (Fig.2). Multiple, small
perfusion defects were also evident in the left upper lobe.
Under the impression of pulmonary embolism, heparin was given
since he arrived the ER. Seven days after he admitted in our
hospital, the patient had multiple episodes of arterial
desaturation and increasing oxygen requirement despite ongoing
anticoagulation with heparin and intubation. The urgent chest
CT scan showed a large embolus at the bifurcation of the main
pulmonary artery, with extension into bilateral pulmonary
arteries (Fig.3). After treatment with intravenous tissue
plasminogen activator, the patient's respiratory status
dramatically improved over a period of several hours, and
approximately 24 hours later, the repeated echography showed
that the right ventricular systolic pressure had decreased to
36 mmHg. He was treated with a heparin infusion for five days
more, and followed by warfarin therapy. An extensive
evaluation of the risk factors of hypercoagulabe state was
also performed. There was no identified coagulation disorder.
Repeated stool occult blood tests were positive, and
panendoscopy was performed which showed a large gastric ulcer
in the cardiac portion. The biopsy showed adenocarcinoma.
Therefore, the patient subsequently received cancer staging,
then operation and chemotherapy for gastric cancer.
|