Selected Topics: Oncological Emergencies| Volume 58, ISSUE 6, P927-931, June 2020

Pulmonary Embolism Can Be Nauseous: A Case Report and Review of D-Dimer Use in Pediatric Oncology Patients



      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Weitz J.I.
        Pulmonary embolism.
        in: Goldman L. Schafer A.I. Goldman's Cecil Medicine, Part 9, Chapter 98. Elsevier, Philadelphia, PA2011: 620-626
        • Wells P.S.
        • Anderson D.R.
        • Rodger M.
        • et al.
        Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED d-dimer.
        Thromb Haemost. 2000; 83: 416-420
        • Wicki J.
        • Perneger T.V.
        • Junod A.F.
        • Bounameaux H.
        • Perrier A.
        Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score.
        Arch Intern Med. 2001; 161: 92-97
        • Tarbox A.K.
        • Swaroop M.
        Pulmonary embolism.
        Int J Crit Illn Inj Sci. 2013; 3: 69-72
        • Pineda L.A.
        • Hathwar V.S.
        • Grant B.J.
        Clinical suspicion of fatal pulmonary embolism.
        Chest. 2001; 120: 791-795
        • Kearon C.
        Natural history of venous thromboembolism.
        Semin Vasc Med. 2001; 1: 27-37
        • Meyer N.J.
        • Schmidt G.A.
        Pulmonary embolic disorders: thrombus, air, and fat.
        in: Hall J.B. Schmidt G.A. Wood L.D. Principles of Critical Care. McGraw-Hill Professional Companies, New York2005: 366-367
        • Lee A.Y.Y.
        • Ginsberg J.S.
        Laboratory diagnosis of venous thromboembolism.
        Baillieres Clin Haematol. 1998; 11: 587-604
        • The PIOPED Investigators
        Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED).
        JAMA. 1990; 263: 2753-2759
        • Hull R.D.
        • Hirsh J.
        • Carter C.J.
        • et al.
        Diagnostic value of ventilation-perfusion lung scanning in patients with suspected pulmonary embolism.
        Chest. 1985; 88: 819-828
        • Stein P.D.
        • Athanasoulis C.
        • Alavi A.
        • et al.
        Complications and validity of pulmonary angiography in acute pulmonary embolism.
        Circulation. 1992; 85: 462-468
        • Wicki J.
        • Perrier A.
        • Perneger T.V.
        • Bounameaux H.
        • Junod A.F.
        Predicting adverse outcome in patients with acute pulmonary embolism: a risk score.
        Thromb Haemost. 2000; 84: 548-552
        • von Löschner J.W.F.
        Phlebitis venae cruralis sinistrae, peri-et myocarditis, embolia et oedema pulmonum.
        Jahrb f Kenderh. 1861; 4: 6
        • Brandao L.R.
        • Labarque V.
        • Diab Y.
        • Williams S.
        • Manson D.E.
        Pulmonary embolism in children.
        Semin Thromb Hemost. 2011; 37: 772-785
        • Biss T.T.
        • Brandão L.R.
        • Kahr W.H.
        • Chan A.K.
        • Williams S.
        Clinical features and outcome of pulmonary embolism in children.
        Br J Haematol. 2008; 142: 808-818
        • van Ommen C.H.
        • Heijboer H.
        • Büller H.R.
        • Hirasing R.A.
        • Heijmans H.S.
        • Peters M.
        Venous thromboembolism in childhood: a prospective two-year registry in the Netherlands.
        J Pediatr. 2001; 139: 676-681
        • Stein P.D.
        • Kayali F.
        • Olson R.E.
        Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey.
        J Pediatr. 2004; 145: 563-565
        • Dijk F.N.
        • Curtin J.
        • Lord D.
        • Fitzgerald D.A.
        Pulmonary embolism in children.
        Paediatr Respir Rev. 2012; 13: 112-122
        • Buck J.R.
        • Connors R.H.
        • Coon W.W.
        • Weintraub W.H.
        • Wesley J.R.
        • Coran A.G.
        Pulmonary embolism in children.
        J Pediatr Surg. 1981; 16: 385-391
        • Rajpurkar M.
        • Warrier I.
        • Chitlur M.
        • et al.
        Pulmonary embolism-experience at a single children’s hospital.
        Thromb Res. 2007; 119: 699-703
        • Le Gal G.
        • Righini M.
        • Roy P.-M.
        • et al.
        Prediction of pulmonary embolism in the emergency department: the revised Geneva score.
        Ann Intern Med. 2006; 144: 165-171
        • Biss T.T.
        • Brandão L.R.
        • Kahr W.H.A.
        • Chan A.K.C.
        • Williams S.
        Clinical probability score and D-dimer estimation lack utility in the diagnosis of childhood pulmonary embolism.
        J Thromb Haemost. 2009; 7: 1633-1638
        • Hennelly K.E.
        • Baskin M.N.
        • Monuteuax M.C.
        • et al.
        Detection of pulmonary embolism in high-risk children.
        J Pediatr. 2016; 178: 214-218
        • Babyn P.S.
        • Gahunia H.K.
        • Massicotte P.
        Pulmonary thromboembolism in children.
        Pediatr Radiol. 2005; 35: 258-274
        • Thacker P.G.
        • Lee E.Y.
        Pulmonary embolism in children.
        AJR Am J Roentgenol. 2015; 204: 1278-1288
        • Victoria T.
        • Mong A.
        • Altes T.
        • et al.
        Evaluation of pulmonary embolism in a pediatric population with high clinical suspicion.
        Pediatr Radiol. 2009; 39: 35-41
        • Stein P.D.
        • Fowler S.E.
        • Goodman L.R.
        • et al.
        Multidetector computed tomography for acute pulmonary embolism.
        N Engl J Med. 2006; 354: 2317-2327
        • von Pohle W.R.
        Pulmonary embolism presenting as acute abdominal pain.
        Respiration. 1996; 63: 318-320
        • Chen K.
        • Lin A.C.
        • Wu C.
        • Wang T.
        • Chua C.
        A 33-year-old man with abdominal pain.
        Emergency. 2016; 4: 166-168
        • Rehman H.
        • John E.
        • Parikh P.
        Pulmonary embolism presenting as abdominal pain: an atypical presentation of a common diagnosis.
        Am J Gastroenterol. 2016; 111: S518
        • Majidi A.
        • Mahmoodi S.
        • Baratloo A.
        • Mirbaha S.
        Atypical presentation of massive pulmonary embolism, a case report.
        Emerg (Tehran). 2014; 2: 46-47
        • Migneault D.
        • Levine Z.
        • de Champlain F.
        An unusual presentation of a massive pulmonary embolism with misleading investigation results treated with tenecteplase.
        Case Rep Emerg Med. 2015; 2015: 868519
        • Alreshq R.
        • Hsu G.
        • Torosoff M.
        Acute pulmonary embolism presenting with symptomatic bradycardia: a case report and review of the literature.
        Am J Case Rep. 2019; 20: 748-752
        • Catella P.
        • Wiesel S.
        • Siddiqui A.H.
        • Chalhoub M.
        C42 Dyspnea: case reports: a rare case of pulmonary embolism induced symptomatic bradycardia.
        Am J Respir Crit Care Med. 2017; : 195
        • Fisher W.T.
        • Reilly K.
        • Salluzzo R.F.
        • et al.
        Atypical presentation of pulmonary embolism.
        Ann Emerg Med. 1990; 19: 1429-1435
        • Reddy T.A.
        • Sheikh W.R.
        • Haldar M.
        • Verma A.
        • Jaiswal S.
        An atypical presentation of massive pulmonary embolism.
        (Available at:)
        • Altınsoy B.
        • Erboy F.
        • Tanrıverdi H.
        • et al.
        Syncope as a presentation of acute pulmonary embolism.
        Ther Clin Risk Manage. 2016; 12: 1023-1028
        • Umar A.
        • Chang E.
        • Bilal M.
        • Faquih M.
        • Ajose T.
        • Bradley C.
        All jerky movements are not seizures: an atypical presentation of massive pulmonary embolism.
        Am J Respir Crit Care Med. 2019; 199
        • Righini M.
        • Le Gal G.
        • De Lucia S.
        • et al.
        Clinical usefulness of D-dimer testing in cancer patients with suspected pulmonary embolism.
        Thromb Haemost. 2006; 95: 715-719
        • Qdaisat A.
        • Wu C.C.
        • Yeung S.J.
        Normal d-dimer levels in cancer patients with radiologic evidence of pulmonary embolism.
        J Thromb Thrombolysis. 2019; 48: 174-179
        • Lee A.Y.Y.
        • Levine M.N.
        Venous thromboembolism and cancer: risks and outcomes.
        Circulation. 2003; 107: I17-I21
        • Raja A.S.
        • Greenberg J.O.
        • Qaseem A.
        • et al.
        Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American College of Physicians.
        Ann Intern Med. 2015; 163: 701-711
        • Wells P.S.
        • Ginsberg J.S.
        • Anderson D.R.
        • et al.
        Use of a clinical model for safe management of patients with suspected pulmonary embolism.
        Ann Intern Med. 1998; 129: 997-1005
        • Lee A.Y.Y.
        • Julian J.A.
        • Levine M.N.
        • et al.
        Clinical utility of a rapid whole-blood d-dimer assay in patients with cancer who present with suspected acute deep venous thrombosis.
        Ann Intern Med. 1999; 131: 417-423
        • Qdaisat A.
        • Soud R.A.
        • Wu C.C.
        • et al.
        Poor performance of d-dimer in excluding venous thromboembolism among patients with lymphoma and leukemia.
        Haematologica. 2019; 104: e265-e268
        • Harringa J.B.
        • Bracken R.L.
        • Nagle S.K.
        • et al.
        Negative d-dimer testing excludes pulmonary embolism in non-high risk patients in the emergency department.
        Emerg Radiol. 2017; 24: 273-280
        • Di Nisio M.
        • Sohne M.
        • Kamphuisen P.W.
        • Büller H.R.
        D-dimer test in cancer patients with suspected acute pulmonary embolism.
        J Thromb Haemost. 2005; 3: 1239-1242