scholarly journals Systemic thrombolysis and anticoagulation improved biomarker measurements in massive-like pulmonary embolism and severe COVID-19 pneumonia: a case report

2020 ◽  
Author(s):  
Hector Betancourt-del Campo ◽  
Carlos Jerjes-Sanchez ◽  
Mauricio Castillo-Perez ◽  
Hector López-de la Garza ◽  
José Gildardo Paredes-Vázquez ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Favourable Outcome ◽  
Clinical Suspicion ◽  
Oxygen Desaturation ◽  
Systemic Thrombolysis ◽  
Normal Ranges ◽  
Asymptomatic Patients ◽  
High Clinical Suspicion ◽  
Wide Range ◽  
D Dimer

Abstract Background From asymptomatic patients to severe acute respiratory distress syndrome, COVID-19 has a wide range of clinical presentations, and venous thromboembolism has emerged as a critical and frequent complication. Case summary We present a case of a 69-year-old man with a clinical presentation of massive-like pulmonary embolism (PE) overlapping with severe COVID-19 pneumonia. The diagnosis was made based on hypotension, severe oxygen desaturation (33%), and right ventricular dysfunction (RVD). We used alteplase and low-molecular-weight heparin, obtaining immediate clinical improvement. Also, we identified an extremely elevated D-dimer (31.2 mcg/mL), and computed tomography pulmonary angiography (CTPA) revealed an unexpected low thrombus burden and a crazy-paving pattern. Considering this, we decided to discontinue the alteplase. Therefore, the mechanisms of pulmonary hypertension and RVD could be multifactorial. Despite the patient’s respiratory status worsening and ongoing mechanical ventilation, biomarkers kept lowering to normal ranges. It appears a favourable outcome was related to early PE diagnosis and a multimodal therapeutic approach. Discussion Physicians in the ER should be warned about extremely high D-dimer measurements and severe oxygen desaturation as possible markers of severe COVID-19 pneumonia in patients with high-clinical suspicion of PE. Although ESC guidelines recommend immediate reperfusion in cardiogenic shock secondary to PE, we suggest initial CTPA in patients with high-clinical suspicion of severe COVID-19.

scholarly journals CORRELATION OF D-DIMER LEVEL WITH THE PRESENCE AND SEVERITY OF PULMONARY EMBOLISM ON COMPUTED TOMOGRAPHY PULMONARY ANGIOGRAPHY

2020 ◽  
pp. 33-34
Author(s):  
Mantavya Patel ◽  
Sanjay Paliwal ◽  
Rachit Saxena
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Early Diagnosis ◽  
Pulmonary Angiography ◽  
Clinical Suspicion ◽  
Early Prediction ◽  
Computed Tomography Pulmonary Angiography ◽  
Negative Prediction ◽  
D Dimer

Introduction: Early diagnosis of pulmonary embolism can reduce morbidity and motility. D-dimer is well known parameter having high negative prediction value. This study focused on role of D-dimer in early prediction of presence and severity of pulmonary embolism. Material and Methods: Thirty patients with clinical suspicion of pulmonary embolism along with high D-dimer value were included in this study. All selected patients underwent computed tomography pulmonary angiography assessment. D-dimer value was correlated with presence and proximity of pulmonary embolism. Results: Out of thirty selected patients 50% had pulmonary embolism on computed tomography pulmonary angiography assessment. D-dimer value correlated well with presence and proximity of pulmonary embolism. Conclusion: D-dimer value more than 4000 ng/ml had high positive prediction value (79%) in suspected clinical cases. Value more than 8000 ng/ml further improve value to nearly 100% in suspected cases.

Platypnoea-orthodeoxia syndrome: the importance of the patient’s posture for diagnosis

2021 ◽  
Vol 14 (6) ◽  
pp. e243210
Author(s):  
Carla Pereira Fontes ◽  
Samuel Barbosa Fonseca ◽  
Mário Santos
Keyword(s):  
Transthoracic Echocardiography ◽  
Rare Condition ◽  
Definitive Diagnosis ◽  
Clinical Suspicion ◽  
Oxygen Desaturation ◽  
Arterial Oxygen ◽  
Common Cause ◽  
Intracardiac Shunt ◽  
High Clinical Suspicion ◽  
Functional Components

Platypnoea-orthodeoxia syndrome (POS) is a rare condition characterised by the association of dyspnoea and arterial oxygen desaturation induced by standing and relieved by recumbency. The precise mechanism remains poorly understood, but it appears to involve both anatomical and functional components producing a significant right-to-left shunting under certain postural conditions. This syndrome is associated with either intracardiac or extracardiac aetiologies, and the diagnosis depends on high clinical suspicion. Intracardiac shunt is the most common cause of POS and can be identified through echocardiography with bubble study. We report the case of a patient with POS secondary to a paradoxical shunt through the patent foramen oval, whose definitive diagnosis was only possible with contrasted transthoracic echocardiography in the sitting and standing positions.

scholarly journals Venous Doppler Ultrasound in Critically Ill Covid-19 Patients: Game Changer in Anticoagulation Therapy

2020 ◽  
Author(s):  
Marta Alfageme ◽  
Jorge González Plaza ◽  
María Luisa Collado ◽  
Santiago Méndez ◽  
Juan A. Gómez Patiño ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Respiratory Failure ◽  
Critically Ill ◽  
Doppler Ultrasound ◽  
Acute Pulmonary Embolism ◽  
Anticoagulation Therapy ◽  
Lower Limbs ◽  
Severe Respiratory Failure ◽  
Asymptomatic Patients ◽  
D Dimer

Abstract BackgroundCOVID-19 infection has been associated with a high rate of thrombotic events, such as deep vein thrombosis (DVT) and acute pulmonary embolism (APE).MethodsThe purpose of our retrospective study was to evaluate the prevalence of asymptomatic DVT in lower limbs in critically ill COVID-19 patients (n=23) with severe respiratory failure and high levels of D-dimer by bedside Doppler ultrasound (DU).ResultsDVT was diagnosed in 14 cases (60.87%), 5 in proximal venous territory and 9 in infrapopliteal veins. CTPA was performed in 6 patients and all of them showed acute pulmonary embolism (APE) at segmental or subsegmental branches of pulmonary arteries. These patients (APE or DVT confirmed) were treated with therapeutic doses of anticoagulant therapy.ConclusionIn critically COVID 19 ill ICU patients with severe respiratory failure y elevated D-dimer the incidence of asymptomatic DVT is high. We propose that DU allows detection of DVT in asymptomatic patients, adding a factor that may balance the decision to fully anticoagulated these patients.

Clinically suspected acute recurrent pulmonary embolism: A diagnostic challenge

2007 ◽  
Vol 97 (06) ◽  
pp. 944-948 ◽  
Author(s):  
Hanneke Kwakkel-van Erp ◽  
Maaike Söhne ◽  
Lidwine Tick ◽  
Marieke Kruip ◽  
Eric Ullmann ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Thrombotic Event ◽  
Diagnostic Algorithm ◽  
Clinical Decision ◽  
Clinical Suspicion ◽  
Diagnostic Challenge ◽  
Recurrent Venous Thromboembolism ◽  
History Of ◽  
D Dimer

SummaryIt is unknown whether strategies validated for diagnosing pulmonary embolism (PE) are valid in patients with a history of PE. It was the objective of this study to investigate whether a diagnostic algorithm consisting of sequential application of a clinical decision rule (CDR), a quantitative D-dimer test and computed tomography (CT) safely ruled out a clinical suspicion of acute recurrent PE. Data were obtained from a diagnostic outcome study of patients suspected of PE. Acute recurrent PE was ruled out by an unlikely probability of PE (CDR score ≤4 points) combined with a normal D-dimer test (≤500 ng/ml) or by a normal CT in all other patients. The primary outcome was the incidence of acute recurrent venous thromboembolism during three months of follow-up in patients with normal tests and not treated with anticoagulants. Of 3,306 patients suspected of acute PE, 259 patients (7.8%) had a history of PE of whom 234 were not treated with anticoagulants. The probability of PE was unlikely in 82 of 234 patients (35%), and 42 had a normal D-dimer test (18%), excluding recurrent PE. None of these patients had a thrombotic event during follow-up (0%, 95%CI: 0–6.9). A CT was indicated in all other patients (192) and ruled out recurrent PE in 127 patients (54%). Only one patient with a negative CT had a fatal recurrent PE during follow-up (0.8%; 95%CI: 0.02–4.3). In conclusion, this prospective study demonstrates the safety of ruling out a clinical suspicion of acute recurrent PE by a simple diagnostic algorithm in patients with a history of PE.

scholarly journals Thoracic Endometriosis: a Clinical Review and Update of Current and Evolving Diagnostic and Therapeutic Techniques

2021 ◽  
Author(s):  
Ravi Kanth Velagapudi ◽  
John P. Egan
Keyword(s):  
Multidisciplinary Approach ◽  
Thoracoscopic Surgery ◽  
Clinical Manifestations ◽  
Clinical Suspicion ◽  
Diagnostic Workup ◽  
Medical Thoracoscopy ◽  
High Clinical Suspicion ◽  
Wide Range ◽  
Thoracic Endometriosis ◽  
Video Assisted Thoracoscopic Surgery

Abstract Purpose of Review The goal of this review is to provide a comprehensive understanding of the pathophysiology, clinical presentation, diagnostic workup, and clinical management of thoracic endometriosis (TE), as well as highlight our personal experience with TE workup and management. Recent Findings TE can present in a wide range of clinical manifestations. Without high clinical suspicion, diagnosis can be delayed. Since no specific laboratory testing is available, diagnosis is often based on careful history taking, imaging, and direct visualization of endometrial lesions through video-assisted thoracoscopic surgery (VATS). Medical thoracoscopy (MT) may also be a useful tool in the diagnostic workup of TE. Summary The diagnosis and management of TE require a multidisciplinary approach and a high index of clinical suspicion. While VATS remains the gold standard for diagnosis, we share our experience using MT to diagnose and manage a case of TE-related hemothorax.

scholarly journals Venous Doppler ultrasound in critically Ill COVID-19 patients: game changer in anticoagulation therapy

2020 ◽  
Vol 12 (1) ◽  
Author(s):  
Marta Alfageme ◽  
Jorge González Plaza ◽  
Santiago Méndez ◽  
Juan A. Gómez Patiño ◽  
María L. Collado ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Respiratory Failure ◽  
Critically Ill ◽  
Doppler Ultrasound ◽  
Acute Pulmonary Embolism ◽  
Anticoagulation Therapy ◽  
Lower Limbs ◽  
Severe Respiratory Failure ◽  
Asymptomatic Patients ◽  
D Dimer

Abstract Background COVID-19 infection has been associated with a high rate of thrombotic events, such as deep vein thrombosis (DVT) and acute pulmonary embolism (APE). Methods The purpose of our retrospective study was to evaluate the prevalence of asymptomatic DVT in lower limbs in critically ill COVID-19 patients (n = 23) with severe respiratory failure and high levels of D-dimer by bedside Doppler ultrasound (DU). Results DVT was diagnosed in 14 cases (60.87%), 5 in proximal venous territory and 9 in infrapopliteal veins. Computed Tomography Pulmonary Angiography (CTPA) was performed in six patients and all of them showed acute pulmonary embolism (APE) at segmental or subsegmental branches of pulmonary arteries. These patients (APE or DVT confirmed) were treated with therapeutic doses of anticoagulant therapy. Conclusion In critically COVID-19 ill ICU patients with severe respiratory failure and elevated D-dimer, the incidence of asymptomatic DVT is high. We propose that DU allows detection of DVT in asymptomatic patients, adding a factor that may balance the decision to fully anticoagulate these patients.

scholarly journals D-dimer dynamics in hospitalized COVID-19 patients: potential utility for diagnosis of pulmonary embolism.

2020 ◽  
Author(s):  
Pau Cerda ◽  
Jesus Ribas ◽  
Adriana Iriarte ◽  
Jose Maria Mora-Lujan ◽  
Raque Torres ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Blood Test ◽  
Clinical Symptoms ◽  
Fold Increase ◽  
Clinical Suspicion ◽  
Test Results ◽  
Potential Utility ◽  
Ct Features ◽  
D Dimer

Background: A higher incidence of thrombotic events, mainly pulmonary embolism (PE), has been reported in hospitalized patients with COVID-19. Objectives: To assess clinical and weekly laboratory differences in hospitalized COVID-19 patients according to occurrence of PE. Methods: This retrospective study included all consecutive patients hospitalized with COVID-19 who underwent a computed tomography (CT) angiography for PE clinical suspicion. Clinical data and median blood test results distributed into weekly periods from COVID-19 symptoms onset were compared between PE and non-PE patients. Results: Ninety-two patients were included, 29 (32%) had PE. PE patients were younger (63.9 (SD13.7) vs 69.9 (SD12.5) years). Clinical symptoms and COVID-19 CT features were similar in both groups. PE was diagnosed after a mean of 20.0 (SD8.6) days from the onset of COVID-19 symptoms. Corticosteroid boluses were more frequently used in PE patients (62% vs. 43%). Median values [IQR] of D-dimer in PE vs non-PE patients were: week 2 (2010.7 [770.1-11208.9] vs 626.0 [374.0-2382.2]; p=0.04); 3 (3893.1 [1388.2-6694.0] vs 1184.4 [461.8-2447.8]; p=0.03); and 4 (2736.3 [1202.1-8514.1] vs 1129.1 [542.5-2834.6]; p=0.01). Median fold-increase of D-dimer between week 1 and 2 differed between groups (6.64 [3.02-23.05] vs 1.57 [0.64-2.71], p=0.003); ROC curve AUC was 0.879 (p=0.003) with a sensitivity and specificity for PE of 86% and 80%, respectively. Conclusions: Among hospitalized COVID-19 patients, D-dimer levels are higher at weeks 2, 3 and 4 after COVID-19 symptom onset in patients who develop PE. This difference is more pronounced when the fold increase between weeks 1 and 2 is compared.

From dyspnea to pulmonary embolism

2009 ◽  
Vol 66 (9) ◽  
pp. 643-647 ◽  
Author(s):  
Arnaud Perrier
Keyword(s):  
Pulmonary Embolism ◽  
Large Body ◽  
Prediction Rule ◽  
Clinical Suspicion ◽  
First Episode ◽  
Left Heart Failure ◽  
Coronary Syndrome ◽  
Clinical Probability ◽  
D Dimer ◽  
Rule Out

Pulmonary embolism (PE) is often evoked in patients with new-onset or worsening dyspnea, especially when it is associated with pleuritic chest pain. However, the prevalence of PE in patients with a clinical suspicion ranges from 20 % to as low as 5 %. Unfortunately, what exactly constitutes a clinical suspicion of PE in a patient with dyspnea can not be accurately standardized. The presence of risk factors for venous thromboembolism should prompt the search for PE. However, their absence does not rule out PE as the cause of the patient’s symptoms, since around 30 % of patients with a first episode of PE have no risk or precipitating factors. Once PE is suspected, the diagnostic workup can be standardized and based on a large body of evidence, combining clinical assessment by a prediction rule, D-dimer measurement and CT angiography in patients with an elevated D-dimer level or a high clinical probability of PE. Patients with obvious alternative diagnoses such as acute left heart failure, pneumonia or acute coronary syndrome should not be investigated for PE.

scholarly journals 974 Paget-Schroetter Syndrome in A Young Fitness Enthusiast with A Negative D-Dimer. Highlighting the Balance Between Clinical Suspicion and Diagnostic Modalities

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
A Gani ◽  
G Lucas ◽  
C Ellis ◽  
A El-Karim ◽  
J Refson
Keyword(s):  
Great Saphenous Vein ◽  
Clinical Suspicion ◽  
Venous Obstruction ◽  
Risk Profiling ◽  
High Clinical Suspicion ◽  
Rare Manifestation ◽  
History Of ◽  
Diagnostic Modalities ◽  
D Dimer ◽  
Collateral Formation

Abstract This case illustrates an athletic 22-year-old, who presented to the hospital with a 3-week history of spontaneous right arm ache, discolouration and swelling. His blood tests were normal, with a negative D-dimer (<150ng/ml). He underwent a CT venogram for suspicion of venous obstruction which was unremarkable. However due to a high clinical suspicion, an ultrasound doppler was performed. This identified the presence of axillary-subclavian thrombosis which in conjunction with other clinical and radiological parameters confirmed the diagnosis of Paget-Schroetter Syndrome (PSS). Our patient was commenced on anticoagulation as the venous obstruction was suspected to be sub-acute with clinical suggestion of collateral formation. Unfortunately, his symptoms failed to resolve over a 6-month period, and he underwent an elective right rib resection with right subclavian bypass using the great saphenous vein with good outcome post-operatively. PSS is a rare manifestation of venous thoracic outlet syndrome (TOS) commonly seen in young, healthy, athletic individuals. Despite the high effectiveness of D-Dimers in ruling out acute thrombotic process and the accuracy of dedicated CT angiography in excluding vascular thrombotic events, both tests proved inconclusive in this particular case. This latter observation highlights the importance of the clinical context, and risk profiling in guiding results interpretation.

Sign in / Sign up

Export Citation Format

Share Document