Teaching Case

Repeated attacks of chest pain and dyspnoea, with a history of thoracic aorta aneurysm, now presented with intense left epigastrium and retrosternal pain associated with dyspnoea.

Patient with repeated attacks of chest pain and dyspnoea –one year ago for the last time. At that time a coronary lesion was eliminated, and regression after NSAF was noted. It was supposed that pain was of vertebral origin, and dyspnoea of combined etiology : mild obstructive ventilation disorder on spirometry (probably aggravated by previous infection) was found, as well as obesity and suspicion for a heart atrium flutter. Pulmonary embolism was eliminated.
CT examination of thorax showed thoracic aorta aneurysm at that time.
Now she presented with intense left epigastrium and retrosternal pain associated with dyspnoea. Nitrates administration was without effect. Clinical examination revealed hypertension, tiredness, dyspnoea, sporadic inspiratory crunches on both lung bases and prolonged expirium with squeaks. No evidence of deep venous thrombosis was seen on ultrasound examination.
A CT examination of the thoracic aorta was performed to eliminate an aortic dissection, but no dissection was found ( image 1, 2 ). Because of a deterioration of pain and dyspnoea after 3 days, contrast-enhanced CT scan of the thoracic aorta was performed to, again, rule out dissection ( image 3). This CT scan demonstrated a hypodense filling defect in the lumen of second - third-order pulmonary vessels, typical for pulmonary embolism and excluded a thoracic aorta dissection.

Pulmonary embolism (PE) is an extremely common and highly lethal condition that is a leading cause of death in all age groups. Prompt diagnosis and treatment can dramatically reduce the mortality rate and morbidity of the disease. Unfortunately, the diagnosis is missed far more often than it is made, because PE often causes only vague and nonspecific symptoms.
Approximately 10% of patients who develop PE die within the first hour, and 30% die subsequently from recurrent embolism. Anticoagulant treatment decreases the mortality rate to less than 5%.
Most patients with DVT develop PE and the majority of cases are unrecognized clinically. Untreated, approximately one third of patients who survive an initial PE die of a future embolic episode. This is true whether the initial embolism is small or large.
Several papers suggest that the incidence of PE may differ substantially from country to country, but no prospective controlled studies support this notion. The observed variance may rather be secondary to differences in the rate of diagnosis than to differences in the frequency of the disease. If the differences are real, whether they are due to genetic variation or to population differences in diet and activity is not known.
The initial chest x-ray (CXR) findings of a patient with PE are usually normal. On rare occasions they may show the Westermark sign, a dilatation of the pulmonary vessels proximal to an embolism along with collapse of distal vessels, sometimes with a sharp cutoff. Over time, an initially normal CXR often begins to show atelectasis, which may progress to cause a small pleural effusion and an elevated hemidiaphragm. After 24-72 hours, one third of patients with proven PE develop focal infiltrates that are indistinguishable from an infectious pneumonia. A rare late finding of pulmonary infarction is the Hampton hump, a triangular or rounded pleural-based infiltrate with the apex pointed toward the hilum, frequently located adjacent to the diaphragm. The CXR is required for proper interpretation of the ventilation/ perfusion lung scan.
Recently, relatively small studies have suggested that contrast enhanced spiral computed tomography (CT) scanning is a useful diagnostic test for pulmonary embolism, with sensitivity as high as 80 percent and specificity as high as 95 percent. Spiral CT is widely available and much less invasive than pulmonary angiography. In many patients, helical CT scans with intravenous contrast can resolve third-order pulmonary vessels without the need for invasive pulmonary artery catheters. If spiral CT, respectively high-resolution helical (spiral) computed tomographic angiography (CTA), could be established as a useful diagnostic test, pulmonary embolism would be diagnosed more effectively and more patients would receive proper treatment.