Critical Care: Student/Resident Case Report Poster - Critical Care V |

Massive Pulmonary Embolism Lurking on the Neurology Unit Masquerading as a Seizure FREE TO VIEW

Alan Nyquist, MD; Charles Read, MD; Jennifer Hilfiker, PA-C
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Medstar Georgetown University Hospital, Washington, DC

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):450A. doi:10.1016/j.chest.2016.08.463
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care V

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary emboli (PE) have a significant burden of morbidity/mortality, particularly when the diagnosis is missed. When they present atypically, the diagnosis can be elusive leading to poor outcomes. Our case of a massive PE presented as new onset seizures.

CASE PRESENTATION: A 19 year old male with no past medical history was brought to the ER after developing new onset seizures at home. Vital signs on presentation included heart rate of 113 beats/minute, blood pressure of 95/58, and pulse oximetry of 87% on room air that quickly normalized. Physical examination including his neurologic status was unremarkable. Workup included a normal head CT, EEG, with subsequent admission to Neurology. The next morning, a repeat generalized tonic-clonic seizure resulted in refractory hypotension, tachycardia, and hypoxemia, prompting a critical care evaluation. The EKG revealed right ventricular strain and a S1Q3T3 finding. On chart review, patient had an elevated D-dimer to 3.28 ng/mL on admission, all raising the suspicion for thromboembolic disease. Stat bedside echo demonstrated RV dilatation and poor function. Subsequent ultrasound of the lower extremities diagnosed acute thrombus. During the workup, he developed further hypotension and hypercapnic respiratory failure requiring intubation that deteriorated to cardiopulmonary arrest. During ACLS, emergent Tissue Plasminogen Activator was administered in addition to cardioversion for supraventricular tachycardia with ROSC after 10 minutes. Repeat bubble echo revealed normal RV function without shunt physiology. Patient was discharged with intact neurologic function 12 days later.

DISCUSSION: Recent literature cites that seizure activity is the presenting symptom of a PE in less than 1% of all cases, most of which are made discovered post mortem due to delays in diagnosis. Like in our case, the elements that make this diagnosis even more difficult are lack of traditional risk factors. Pathophysiologically, it is felt that an embolus causes both hypoxemia and reduced cardiac output that leads to inadequate cerebral perfusion with subsequent seizure activity. Therefore, while seizure may be the first symptom, progression of the embolus can lead to a catastrophic cardiopulmonary outcome.

CONCLUSIONS: The etiology of new-onset seizures includes a broad differential making it difficult to promptly diagnose. While PEs are not traditionally associated with new onset seizures, this case demonstrates a reason to consider thromboembolic disease particularly in the unstable patient.

Reference #1: Meyer, Michael Andrew. “Seizure as the presenting sign for massive pulmonary embolism: Case report and review of the literature.” Seizure 18.1 (2009): 76-78.

Reference #2: Shah, A. K., and M. Darwent. “Acute pulmonary embolism presenting as seizures.” Emergency Medicine Journal 26.4 (2009): 299-300.

Reference #3: Volz, Emilio EG, and Neil Jasani. “Seizure as a presentation of pulmonary embolism.” The Journal of emergency medicine 46.1 (2014): e1-e4.

DISCLOSURE: The following authors have nothing to disclose: Alan Nyquist, Charles Read, Jennifer Hilfiker

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