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Case 268

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A 73-year-old male patient admitted to the emergency room with progressive dyspnea of abrupt worsening, dry cough, tachypnea, and severe, ventilator-dependent chest pain in the dorsal region. He presented orthopnea, paroxysmal nocturnal dyspnea and hemoptysis for more than three weeks, and weight loss of 5kg in one month. He also reported three recent episodes of pneumonia, with no improvement in antibiotic therapy, and negative sputum acid-fast bacilli smear. On the exam: HR = 92 bpm, RR = 27 bpm, SpO2 below 90%, sparse snores and crackles at the base of the right lung. Attached images were performed.

Analyzing the clinical case and the images presented, which examination was essential for the definition of the diagnosis and the therapeutics?

a) CT Angiography - Pulmonary thromboembolism

25%

b) Computed Tomography - Pulmonary tuberculosis

25%

c) Computed Tomography - Pulmonary neoplasia

25%

d) Simple X-ray - Community-acquired pneumonia

25%
   

Image analysis

Image 1: Computed Tomography Angiography of the thorax, axial cut, infracarinal level, after iodinated venous contrast, evidencing vascular trunk of the pulmonary artery with caliber at the upper limit of normality. Signs of filling failures on the left branch and on right lobular branches, to the lower lobe (red arrows). Bilateral pleural effusion, small on the left and moderate on the right (in green). Heart with enlarged dimensions (dashed line).

 

Image 2: Alterations in coronal section, with greater evidence of opacification on the cited branches (red arrows) and wedge lesion area, with base extended to the periphery, suggestive of pulmonary infarction in the lateral basal segment of the right lower lobe (in pink).

 

Image 3: Chest CT without intravenous contrast medium. Axial cut, infracarinal level, and lung window (compatible with Images 1A and 1B) showing wedge lesion consolidation with widened base to the periphery (in pink) on the topography of the anterior basal segment of the right lower lobe with adjacent ground-glass opacity . Discreet pleural effusion to the right and laminar to the left (in green).

 


Image 4: Chest X-ray in PA film. The right pulmonary base veil is observed, associated with the anterior border of the inferior lobe (blue arrows) with diaphragm erasure. Increased CTR (cardiothoracic ratio) (dashed line).

Highlights

- Pulmonary thromboembolism is often underdiagnosed and should be suspected in patients presenting with chest pain, dyspnea, tachypnea and/or hemodynamic instability;

- The Wells score for pulmonary thromboembolism or Modified Geneva should be used in the clinical evaluation;

- CT Angiography of the Chest is usually the examination of choice except in the presence of contraindications;

- D-dimer is useful to exclude pulmonary and venous thromboembolism because of its high negative predictive value (high sensitivity), but its value above the reference has no clinical or therapeutic significance;

- Therapy is based primarily on the use of thrombolytics and anticoagulation. Low molecular weight heparin or fondaparinux is the conventional therapy for hemodynamically stable patients in the in-hospital environment.

References

- Emergências Clínicas uma Abordagem Prática. 11th Edition. São Paulo: Editora Manole; 2016.

- Muller CIS, et al. Tórax. 1st Edition. Rio de Janeiro: Colégio Brasileiro de Radiologia e Diagnóstico por Imagem; 2010.

- SUN Z, et al. Coronary CT angiography: current status and continuing challenges. Br J Radiol. 2012; 85(1013), 495–510.

- Dunne RM, et al. Effect of Evidence-based Clinical Decision Support on the Use and Yield of CT Pulmonary Angiographic Imaging in Hospitalized Patients. Radiology, 2015; 276(1).

- Dogan H, et al. The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism. Diagn Interv Radiol. 2015; 21: 307–16.

- Alvares F, de Pádua AI, Filho JT. Tromboembolismo pulmonar: diagnostico e tratamento. Medicina, Ribeirão Preto. 2003; 36: 214-40.

Authors

André Dias Nassar Naback, 5th year medical student at Universidade Federal de Minas Gerais

E-mail: andrenaback[at]gmail.com

 

Júlia Salles Rezende Dias, 5th year medical student at Universidade Federal de Minas Gerais

E-mail: juliasallesrd[at]gmail.com

 

Giovanna Vieira Moreira, 5th year medical student at Universidade Federal de Minas Gerais

E-mail: giovieiramoreira[at]gmail.com

Supervisors

Professor José Nelson Mendes Vieira, Radiologist and Professor of the Department of Anatomy and Image of the Federal University of  Minas Gerais.

Reviewers

Laio Bastos, Carla Faraco, Thiago Heringer, Pétala Silva and Professor Viviane Parisotto

Translated by

Ricardo Mazilão Silva, 4th year medical student at Universidade Federal de Minas Gerais.

E-mail: silvaricardomz[at]gmail.com

 

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