Author: V. Dimov, M.D.
Reviewer: A. Aneja, M.D.
A 72-year-old African American female (AAF) is admitted to the hospital with CC: increasing leg edema and weakness. In the emergency room (ER), she was noted to be in supraventricular tachycardia (SVT), and despite 3 doses of adenosine (Adenocard), she did not respond, and was brought to the intensive care unit (ICU). Currently, she is on Cardizem (diltiazem) drip. On admission, she is coughing w/o bringing up any phlegm, and appears to be dyspneic on minimal exertion. She is not able to give any details of her present or PMH.
Past medical history (PMH)
Hypertension (HTN), recurrent SVTs in the past, diverticulitis and emergency sigmoidectomy, colostomy, gout, hypercholesterolemia, noncompliant.
The patient has not been compliant with medications and she does not know their names.
Social history (SH)
Lives with her daughter. Heavy smoker for 30 years.
VS T 35.9, HR has varied from 130 to 90, BP 128/71, RR 17.
Chest: scattered wheezing (B).
CVS: Clear S1S2, irregular rhythm, no gallops or murmurs.
Abdomen: colostomy bag with formed, dark stools but no evidence of melena.
Extremities: LLE warm, erythematous skin with 2+ pitting edema, RLE is also swollen but not red.
What is the most likely diagnosis?
It could be a lot of things:
Congestive heart failure (CHF) exacerbation due to ischemia, Atrial fibrillation with rapid ventricular response (AFib with RVR).
Pulmonary embolism (PE).
Deep venous thrombosis (DVT).
What laboratory workup would you suggest?
CBCD, CMP, INR/PTT, UA, CXR, EKG, CPP x 2, BNPep.
BUN and creatinine are at baseline. LFTs are normal. Two sets of cardiac enzymes are negative for myocardial ischemia. BNPeptide is minimally elevated at 133. EKG shows atrial fibrillation.
CXR: Interstitial pulmonary edema and (B) pleural effusions. Cardiac silhouette is markedly enlarged. Mediastinal contours are unchanged (click to enlarge the images).
The patient was treated for CHF exacerbation and pneumonia.
LE Duplex showed a LLE DVT. Heparin IV and Coumadin (warfarin) PO were started. She continued to complain (c/o) shortness of breath (SOB). A CT of the chest was ordered which showed extensive (B) PE and thoracic aortic dissection.
Coumadin (warfarin) was stopped and INR was reversed. A cardiothoracic surgical consult was called urgently.
The surgeon discussed the case with the patient and the family, explaining the risks of a surgical intervention in a patient with multiple comorbidities. The patient's family decided to pursue conservative treatment.
CT of the chest
Bilateral PE, more in the left pulmonary artery, aortic aneurysm and dissection; Close-up on the thrombus in the left pulmonary artery (click to enlarge the images).
Bilateral PE, more in the left pulmonary artery, aortic aneurysm and dissection (click to enlarge the images).
Report of CT thorax with IV contrast:
Technique: Using 125 cc of nonionic IV contrast, spiral CT of the chest was performed using the PE protocol which does not include the lung apices or bases.
Findings: There is a 4 cm descending thoracic aortic aneurysm with either an aortic dissection and thrombosed right sided lumen versus marked thrombus in the aneurysm. Low density fluid surrounds the descending thoracic aorta worrisome for leaking aneurysm. The ascending thoracic aorta measures 3.8 cm. The aortic arch measures 3 cm. There is a large pericardial effusion and cardiomegaly. There are extensive (B) pulmonary emboli. There is (B) lower lobe atelectasis with (B) pleural effusions. Thoracic surgery consultation is suggested.
CT of the abdomen
AAA with calciffications; Thrombus in IVC and aorta (click to enlarge the images).
IVC filter (click to enlarge the images).
Report of CT abdomen with PO and IV contrast:
Since 2 years ago, there is unchanged AAA measuring 4 cm x 5 cm at the level of the adrenal glands. There is asymmetric large margin of thrombus within the aorta was smooth internal margin and narrowing of the contrast filled lumen having the appearance of an extensive aortic dissection which extends from the thorax to at least the level of the aortic bifurcation. There is an IVC filter. There is thrombus within the IVC proximal and distal to the filter. There is thrombus within the left common femoral vein extending into the proximal left leg.
Pulmonary embolism (PE) and thoracic aortic dissection.
Dissection, Aortic. eMedicine.
Pulmonary Embolism Paths. A free Palm program, Palmdoc Chronicles, 2007.
A Sense of Doom. ER Stories, 03/2008.
A classic respiratory case. Life in the Fast Lane.