Pulmonary Thromboembolism 11_16_2011

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

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

??? 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

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

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

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

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

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.