Abstract
Background
Pulmonary embolism (PE) is a very common presentation in the emergency department
(ED). Despite being life-threatening, PE is preventable if diagnosed and managed early,
especially in high-risk patients like pediatric oncology patients. A negative d-dimer has a high negative predictive value and can rule out PE in low-risk patients;
however, it does not lower post-test probability enough and should be coupled with
further diagnostics in high-risk patients.
Case Report
We describe the case of a 14-year-old girl known to have acute lymphoblastic leukemia
and presented to the ED with persistent nausea and vomiting only, which was exacerbated
by exertion. She had previously presented to the ED 1 week earlier for the same complaint,
with a nonrevealing physical examination. At that time, the patient was worked up
for nausea and vomiting and received symptomatic treatment. An electrocardiogram (ECG)
during that presentation showed normal sinus rhythm. During this presentation, ECG
showed new ST segment depressions from V1 to V6 in addition to an S1Q3T3 pattern.
This, coupled with the exacerbation of her initial symptoms, triggered further investigations.
Computed tomography angiography (CTA) of the chest was performed and showed a right
lower lobe segmental pulmonary artery embolus.
Why Should an Emergency Physician Be Aware of This?
This case highlights the importance of having a high level of suspicion for PE, especially
in pediatric oncology patients and specifically in hematologic malignancies. Although
our patient's presentation, examination, and laboratory results were not concerning
initially, CTA of the chest showed a PE. We are addressing this particular topic to
increase the awareness of emergency physicians of cases like this, as PE can have
an unusual presentation and missing such a diagnosis can be fatal.
Keywords
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Article info
Publication history
Published online: January 27, 2020
Accepted:
December 9,
2019
Received in revised form:
November 15,
2019
Received:
August 15,
2019
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
