SESSION TYPE: Miscellaneous Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: This is a case of a patient presenting with shortness of breath and radiologic evidence of a Westermark sign on chest x-ray.
CASE PRESENTATION: A 69 year old Caucasian female presents to the emergency department with shortness of breath and substernal pressure. Past medical history is significant for a pulmonary embolism 30 years ago treated with Coumadin for 12 months. Patient had a recent visit to the emergency department two weeks prior for syncope and was discharged home with a diagnosis of vasovagal syncope. On physical exam, the patient had an accentuated P2 with no murmurs and diminished breath sounds at the right lung base. Chest X-ray showed oligemia in the upper and middle zone of the right lung, described as Westermark sign. (Figure 1) The decreased vasculature was evident in spite of compressive atelectasis, which is expected to show increased vasculature. CT angiogram of the chest showed large pulmonary emboli mostly in the right vasculature, involving the right upper and lower lobe pulmonary artery, their distal interlobular segmental branches, and the segmental branches of the left upper, lower and lingular pulmonary artery. (Figure 2) Echocardiography showed a dilated right ventricle (RV) with decreased systolic function. An increased RV pressure has caused bulging of the interventricular septum, suggestive of right ventricular overload forming the “D” sign, consistent with acute PE. (Figure 2)
DISCUSSION: Plain film evidence of Westermark sign is not often seen. In this case, the Westermark sign is evident in the right upper lung zones. This is confirmed by CT angiography of the chest, which shows large clot burden obstructing the right pulmonary artery. Another interesting chest radiographic finding is an elevated right hemidiaphragm. Typically, prominence of the vessels secondary to the compression of the lung parenchyma would be seen. However, the extent of the oligemia blunts the prominence of the vasculature.
CONCLUSIONS: In conclusion, this case illustrates evidence of pulmonary embolism in the form of Westermark sign, vascular filling defect, and increased right ventricular pressure through chest x-ray, CT angiography and echocardiogram, respectively.
1) Subramanian Krishnan, A., & Barrett, T. (2012). Westermark sign in pulmonary embolism. The New England Journal of Medicine, 366(11).
2) Piazza D, Goldhaber SZ. (2006). Acute pulmonary embolism: epidemiology and diagnosis. Circulation, 114: e28-e32.
DISCLOSURE: The following authors have nothing to disclose: Maricarmen Roche Rodriguez, Michael Apostolis, Ragheb Assaly
No Product/Research Disclosure InformationThe University of Toledo College of Medicine, Toledo, OH