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48-Year-Old Woman with Acute-Onset Cough, Chest Tightness, and Shortness of Breath
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2016.06.053
Visual Diagnosis in Emergency Medicine
48-YEAR-OLD WOMAN WITH ACUTE-ONSET COUGH, CHEST TIGHTNESS, AND SHORTNESS OF BREATH Rebecca A. Lowy, MS4, Richard Pescatore, DO, Jillian C. Smith, MD, and Holly A. Bartimus, MD Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School Rowan University, Camden, New Jersey Reprint Address: Holly A. Bartimus, MD, Emergency Department, Cooper University Hospital, 1 Cooper Plaza, Suite 152, Camden, NJ 08103
CASE REPORT A 48-year-old woman presented to the Emergency Department (ED) with complaint of acute-onset shortness of breath, cough, and chest tightness. She denied any fever, chills, hemoptysis, vomiting, or lower extremity edema. Her past medical history was significant for metastatic breast cancer status post bilateral mastectomy and a recently diagnosed right upper lobe lung mass for which bronchoscopic biopsy was performed one day prior to ED evaluation. On presentation, she was mildly tachycardic (heart rate 105 beats/min) and tachypneic (respiratory rate 20 breaths/min). Blood pressure, pulse oximetry, and oral temperature were within normal limits. Physical examination was without other significant findings. Computed tomography (Figures 1 and 2) of the chest was performed. DIAGNOSIS/DISCUSSION
Figure 1. Coronal view of chest computed tomography scan, pulmonary embolism protocol, showing thrombus in the right pulmonary vein.
Pulmonary vein thrombosis (PVT) is an infrequently reported condition that may be idiopathic in nature or may arise secondarily due to lung surgeries, such as transplantation or lobectomy, ablation, malignancy, or a variety of other conditions unrelated to surgery (1–5). In the reported cases, particularly those with no history of recent surgery, presentation occurs almost exclusively in adults, and presenting symptoms may be
nonspecific, including chest discomfort, cough, dyspnea, or hemoptysis (1,6,7). Diagnosis of PVT is often made via computed tomography (CT) imaging, but can also be detected by transesophageal echocardiography (TEE), magnetic resonance imaging, or pulmonary angiography. Although pulmonary
RECEIVED: 17 February 2016; FINAL SUBMISSION RECEIVED: 16 June 2016; ACCEPTED: 29 June 2016 1
2
R. A. Lowy et al.
found to have PVT (3). A more recent study done in 2014 by Takeuchi addressed the prevalence of PVT using CT rather than TEE (8). In this study of 56 consecutive older patients with chest pain and no other risk factors for PVT, CT scan was positive in 61% of patients. This brings into question whether CT is a better imaging modality than TEE for evaluation of PVT. In addition, more studies are needed to better ascertain the true prevalence of and clinical significance of PVT. Our patient was admitted for progressive dyspnea and was started on anticoagulation therapy with enoxaparin. After an extended hospital course, she was discharged to a rehabilitation facility given substantial deconditioning secondary to extensive progression of metastatic disease. REFERENCES
Figure 2. Axial view of chest computed tomography scan, pulmonary embolism protocol, showing thrombus in the right pulmonary vein.
embolism is a well-known clinical entity with defined management strategies, there are no definitive treatment guidelines for PVT, and management with anticoagulation is the most commonly cited treatment in the literature. Recently, there has been suggestion that PVT is both under-diagnosed and important to recognize given the risk of systemic embolization (6,8). In a prospective study by Schulman et al. in 2001, TEE was performed on 87 consecutive lung transplant patients 48 hours post surgery to assess clot formation at the pulmonary vein anastomotic site; 15% of those patients were
1. Selvidge SDD, Gavant ML. Idiopathic pulmonary vein thrombosis: detection by CT and MR imaging. AJR Am J Roentgenol 1999; 172:1639–41. 2. Schmitt ER, Burg MD. More than just another pulmonary embolism: images in emergency medicine. West J Emerg Med 2012;13:98–9. 3. Schulman LL, Anandarangam T, Leibowitz DW, et al. Four-year prospective study of pulmonary venous thrombosis after lung transplantation. J Am Soc Echocardiogr 2001;14:806–12. 4. Yataco J, Stoller JK. Pulmonary venous thrombosis and infarction complicating pulmonary venous stenosis following radiofrequency ablation. Respir Care 2004;49:1525–7. 5. Saoraya J, Inboriboon PC. Pulmonary vein thrombosis associated with a large hiatal hernia. J Emerg Med 2013;44:e299–301. 6. Vazquez FJ, Paulin P, Rodriguez P, et al. The outcome of pulmonary vein thrombosis in non-surgical patients. A systematic review and case report. Thromb Haemost 2015;113:1151–4. 7. Kim NH, Roldan CA, Shively BK. Pulmonary vein thrombosis. Chest 1993;104:624–6. 8. Takeuchi H. High prevalence of pulmonary vein thrombi in elderly patients with chest pain, which has relationships with aging associated diseases. IJC Heart Vessels 2014;4:129–34.
http://dx.doi.org/10.1016/j.jemermed.2016.06.053
Visual Diagnosis in Emergency Medicine
48-YEAR-OLD WOMAN WITH ACUTE-ONSET COUGH, CHEST TIGHTNESS, AND SHORTNESS OF BREATH Rebecca A. Lowy, MS4, Richard Pescatore, DO, Jillian C. Smith, MD, and Holly A. Bartimus, MD Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School Rowan University, Camden, New Jersey Reprint Address: Holly A. Bartimus, MD, Emergency Department, Cooper University Hospital, 1 Cooper Plaza, Suite 152, Camden, NJ 08103
CASE REPORT A 48-year-old woman presented to the Emergency Department (ED) with complaint of acute-onset shortness of breath, cough, and chest tightness. She denied any fever, chills, hemoptysis, vomiting, or lower extremity edema. Her past medical history was significant for metastatic breast cancer status post bilateral mastectomy and a recently diagnosed right upper lobe lung mass for which bronchoscopic biopsy was performed one day prior to ED evaluation. On presentation, she was mildly tachycardic (heart rate 105 beats/min) and tachypneic (respiratory rate 20 breaths/min). Blood pressure, pulse oximetry, and oral temperature were within normal limits. Physical examination was without other significant findings. Computed tomography (Figures 1 and 2) of the chest was performed. DIAGNOSIS/DISCUSSION
Figure 1. Coronal view of chest computed tomography scan, pulmonary embolism protocol, showing thrombus in the right pulmonary vein.
Pulmonary vein thrombosis (PVT) is an infrequently reported condition that may be idiopathic in nature or may arise secondarily due to lung surgeries, such as transplantation or lobectomy, ablation, malignancy, or a variety of other conditions unrelated to surgery (1–5). In the reported cases, particularly those with no history of recent surgery, presentation occurs almost exclusively in adults, and presenting symptoms may be
nonspecific, including chest discomfort, cough, dyspnea, or hemoptysis (1,6,7). Diagnosis of PVT is often made via computed tomography (CT) imaging, but can also be detected by transesophageal echocardiography (TEE), magnetic resonance imaging, or pulmonary angiography. Although pulmonary
RECEIVED: 17 February 2016; FINAL SUBMISSION RECEIVED: 16 June 2016; ACCEPTED: 29 June 2016 1
2
R. A. Lowy et al.
found to have PVT (3). A more recent study done in 2014 by Takeuchi addressed the prevalence of PVT using CT rather than TEE (8). In this study of 56 consecutive older patients with chest pain and no other risk factors for PVT, CT scan was positive in 61% of patients. This brings into question whether CT is a better imaging modality than TEE for evaluation of PVT. In addition, more studies are needed to better ascertain the true prevalence of and clinical significance of PVT. Our patient was admitted for progressive dyspnea and was started on anticoagulation therapy with enoxaparin. After an extended hospital course, she was discharged to a rehabilitation facility given substantial deconditioning secondary to extensive progression of metastatic disease. REFERENCES
Figure 2. Axial view of chest computed tomography scan, pulmonary embolism protocol, showing thrombus in the right pulmonary vein.
embolism is a well-known clinical entity with defined management strategies, there are no definitive treatment guidelines for PVT, and management with anticoagulation is the most commonly cited treatment in the literature. Recently, there has been suggestion that PVT is both under-diagnosed and important to recognize given the risk of systemic embolization (6,8). In a prospective study by Schulman et al. in 2001, TEE was performed on 87 consecutive lung transplant patients 48 hours post surgery to assess clot formation at the pulmonary vein anastomotic site; 15% of those patients were
1. Selvidge SDD, Gavant ML. Idiopathic pulmonary vein thrombosis: detection by CT and MR imaging. AJR Am J Roentgenol 1999; 172:1639–41. 2. Schmitt ER, Burg MD. More than just another pulmonary embolism: images in emergency medicine. West J Emerg Med 2012;13:98–9. 3. Schulman LL, Anandarangam T, Leibowitz DW, et al. Four-year prospective study of pulmonary venous thrombosis after lung transplantation. J Am Soc Echocardiogr 2001;14:806–12. 4. Yataco J, Stoller JK. Pulmonary venous thrombosis and infarction complicating pulmonary venous stenosis following radiofrequency ablation. Respir Care 2004;49:1525–7. 5. Saoraya J, Inboriboon PC. Pulmonary vein thrombosis associated with a large hiatal hernia. J Emerg Med 2013;44:e299–301. 6. Vazquez FJ, Paulin P, Rodriguez P, et al. The outcome of pulmonary vein thrombosis in non-surgical patients. A systematic review and case report. Thromb Haemost 2015;113:1151–4. 7. Kim NH, Roldan CA, Shively BK. Pulmonary vein thrombosis. Chest 1993;104:624–6. 8. Takeuchi H. High prevalence of pulmonary vein thrombi in elderly patients with chest pain, which has relationships with aging associated diseases. IJC Heart Vessels 2014;4:129–34.