Pulmonary Embolism

A 52-year-old woman who was undergoing chemotherapy for lymphoma was admitted to the hospital with fever of a few days' duration. The patient had smoked cigarettes for many years; she had no history of deep venous thrombosis.

On the third day of hospitalization, the patient complained of severe pleuritic chest pain of sudden onset in the left hemithorax. She became diaphoretic; blood pressure was 70/40 mm Hg; pulse rate, 136 beats per minute; and respiration rate, 30 breaths per minute. Profound hypoxemia was revealed by a PaO₂ level of 55 mm Hg on room air.

A loud P₂ (pulmonic valve component of the second heart sound) was heard; the rest of the examination, including lung assessment, was unremarkable. Drs Manjula Thopcherla, Sonia Arunabh, and Arunabh of North Shore University Hospital at Forest Hills, NY, write that the chest film did not reveal an infiltrate or effusion; however, a CT scan of the chest with angiography demonstrated a clot in the left main pulmonary artery. Doppler studies confirmed very deep venous thrombosis in the right leg.

The hemodynamically unstable patient was treated initially with tissue plasminogen activator; later, she was given heparin and subsequently warfarin. Within a few days, the hypoxemia resolved and the patient's cardiovascular status stabilized; she was discharged from the hospital and advised to continue the warfarin.

Thrombolytic therapy with tissue plasminogen activator is appropriate for patients with massive pulmonary artery embolism who are hemodynamically unstable. Contraindications include active internal bleeding, recent cerebrovascular accident, pregnancy, and uncontrolled coagulation defects. Complications such as intraperitoneal and intracranial bleeding may occur.