History of Present Illness
A 21-year-old Caucasian woman went to the emergency room complaining of cough, with three episodes of mild hemoptysis. The previous day she had a high fever (40° C [104° F]). Moreover, she had been undergoing physiotherapy for middle and low back pain for a week.
Past Medical History
The patient’s past medical history was unremarkable, except for common childhood infectious diseases and pyelonephritis at age 16 years. The patient, who worked as a shop assistant, was thin but with normal physical measurements (height 155 cm, weight 49 kg, body mass index [BMI] = 20.4). She reported smoking a few cigarettes a day and engaging in regular physical activity three times a week. She had been taking a combined estrogen–progestogen oral contraceptive for about 8 months. No previous drug adverse events were reported.
Physical Examination and Early Clinical Findings
The patient was alert, and the temperature had come down to 37.5° C (99.5° F), but she had just taken paracetamol 1000 mg. Physical examination revealed several red circles on the skin of her left back ( Fig. 17.1 ) resulting from undergoing a traditional Chinese massage technique, in which suction cups are used for pain relief (the so-called cupping therapy). Reduction of breath sounds and dullness to percussion at the left lower chest were evident. Oxygen saturation (Sp O 2 ) was 98% in room air, arterial blood gas (ABG) analysis showed normal partial pressure of carbon dioxide (Pa CO 2 39 mm Hg) and partial pressure of oxygen (Pa O 2 88 mm Hg).
Electrocardiography (ECG) demonstrated sinus tachycardia at 100 beats/min. Chest radiography and ultrasonography showed unilateral left pleural effusion and slight ipsilateral consolidation of the pulmonary parenchyma, with a vascular sign at the margin ( Figs. 17.2 and 17.3 ). Blood tests revealed an increase in inflammatory markers (C-reactive protein [CRP]: 42 mg/L; normal values < 5 mg/L) and leukocytosis (white blood cell [WBC] count: 12,500 cells/μL).
Empirical therapy was begun, including broad-spectrum antibiotics (ceftriaxone 1 g intravenously once a day plus oral azithromycin 500 mg once a day), and analgesics (paracetamol 1 g orally, as needed). The same day the patient was admitted to the pulmonology unit.
Clinical Course
It was determined that the patient was at moderate risk for pulmonary embolism, according to the Well’s criteria. D -dimer was elevated (620 ng/mL, normal values < 250 ng/mL); thus the patient underwent computed tomography pulmonary angiography (CTPA), which showed filling defects caused by emboli in the left lower lobe segmental artery and the subsegmental branches supplying the anteromedial and lateral basal segments. CTPA also confirmed left pleural effusion and revealed irregular lung hyperdensity in the left lower lobe suggestive of pulmonary hemorrhage and infarction ( Fig. 17.4 ).
Computed tomography pulmonary angiography (CTPA) (See )
Echocardiography showed normal size and function of the right atrium and ventricle, without any increase in arterial pulmonary pressure. Color Doppler ultrasonography excluded deep venous thrombosis (DVT) of lower limbs. Anticoagulant therapy was initiated with the subcutaneous injection of fondaparinux 5 mg once daily (which is the therapeutic dosage for people weighing < 50 kg). The patient experienced progressive clinical improvement and no longer had a fever or hemoptysis. The tuberculin skin test with 5 tuberculin units (TU) yielded a negative result. Blood and sputum cultures showed no growth. After a few days, the back pain occurred only during exertion or deep breathing, and pleural effusion decreased. No invasive procedure was performed.
Therapy and Further Indications at Discharge
The patient was discharged after 6 days of hospitalization. The oral contraceptive pill was discontinued. A direct oral anticoagulant (DOAC) was prescribed as home therapy (edoxaban, 30 mg once a day, which is the therapeutic dosage for people weighing < 60 kg).
The following outpatient follow-up was scheduled:
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After 1 month: Thrombophilia screening (to be repeated in case of any positivity) and chest radiography
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After 3 months: Single-photon emission computed tomography (SPECT) and pulmonary function tests
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After 6 months: Echocardiography.
Follow-Up and Outcomes
The patient experienced complete alleviation of pain within 2 weeks after discharge, and she no longer used pain relievers. No bleeding complications occurred. The patient resumed light physical activity, with good exercise tolerance. The chest ultrasonography and radiography results were normal ( Fig. 17.5 ). Pulmonary function tests showed global volumes and lung diffusion capacity within normal limits. SPECT performed 3 months after the acute episode showed a large triangular fixation defect (lack of perfusion) of the radiopharmaceutical in the posterolateral region of the left lower lung lobe ( Fig. 17.6 ).
