1. Pulmonary Thromboembolism
11_16_2011

2. HPI
17 yo female developed shortness of breath while doing a mild run at school
O2 sat 91% in nurse’s office
Sent to ED
Sat drops to 83% while running in place
ROS:
No cough, fever, wheeze, syncope, hemoptysis, chest pain
Completely negative
PMH: Hemolytic anemia as a child requiring blood transfusions until splenectomy

3. ED
Normal CXR, nl EKG
CT scan to evaluate for pulmonary embolus – negative
D-dimer – high normal – cannot rule out PE, but low probability

4. ??? Why is she hypoxic? No signs of V/Q mismatch Shunt?
O2 increases when she is given supplemental O2
This can be seen in hepatopuolmonary syndrome but she has no liver disease
Diffusion abnormality?
No evidence of pulmonary hypertension on echo
Negative cardiac workup including negative bubble study
Spirometry normal
Methemoglobin negative

5. Labs Hct 29.1 ESR/CRP nl Negative hypercoag panel
IgG to aspergillus elevated

6. HPI Continued to have sats in low to mid 90’s but asymptomatic at rest
Negative V/Q scan
Repeat CT scan
Nodule vs infarct

7. What to do
17 yo with hypoxia at rest who significantly desaturates with very mild exercise
Labs and physical examination unremarkable
Question of lung nodule on CT scan

8. Lung Biopsy
Hemorrhagic infarct: pulmonary microthrombotic phenomenon due to chronic hemolysis complicated by splenectomy

9. Treated with lovenox and sats improved to 97-98%
Chronic hemolysis causing micro thromboemboli which led to decreased diffusion and dec. sats.
Since lovenox helped, pt must have been continuously showering her lungs with thromboemboli…
Has subsequently been placed on coumadin and is doing well.