Pulmonary Vascular Disease: Fellow Case Report Slide: Venous Thromboembolic Disease |

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Ala Eddin Sagar, MD; Farah Kazzaz, MD; Soma Jyothula, MD
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University of Texas at Houston, McGovern Medical School, Sugar Land, TX

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

Chest. 2016;150(4_S):1146A. doi:10.1016/j.chest.2016.08.1256
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SESSION TITLE: Fellow Case Report Slide: Venous Thromboembolic Disease

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 25, 2016 at 04:30 PM - 05:30 PM

INTRODUCTION: There is little evidence to support whether or not to treat patients with subsegmental pulmonary emboli (SSPE) given the poor understanding of their natural course. We present a patient with persistent hemoptysis with no radiographic findings of PE, who had a SSPE causing a pulmonary infarct.

CASE PRESENTATION: A 47 year old female with history of hypothyroidism, presents with hemoptysis, estimated to be 2 cups of blood over 2 days. Exam was unremarkable except for rales in the upper zone of the left lung. Chest X-ray was normal. Computed tomographic angiography showed relative lucency of the left upper lobe, ground glass opacity in the rest of the lung, with no visible PE, AV malformation or endobronchial tumor. Bronchial artery angiogram demonstrated normal vascularity bilaterally. She was incidentally noted to have a right femoral vein thrombus during the procedure. She continued to have hemoptysis, and had a bronchoscopy revealing clots in the main airway, with blood oozing from the left upper lobe. Due to the persistent hemoptysis, she underwent a VATS left upper lobectomy. Hemorrhagic changes of the apical segment of the left upper lobe were noted. Pathology showed a hemorrhagic infarct, with sharp demarcation from the normal lung parenchyma, and no evidence of neoplasms, vasculitis or infection. She was diagnosed with a SSPE causing a pulmonary infarction and was started on anticoagulation.

DISCUSSION: The use of CT scans has increased significantly over the last decade, with a noticeable increase in the incidence of PE. Interestingly, the increase in incidence has not been accompanied by a change in mortality, arguing that we may be diagnosing “harmless” SSPEs1. The diagnosis of SSPEs is affected by the interobserver variability between radiologists and the predictive value of the CT2. Controversy remains as to whether anticoagulation is required due to the conflicting evidence. While some may argue that SSPEs are harmless, we hereby present a case of persistent life-threatening hemoptysis, caused by a SSPE which CTA failed to detect.

CONCLUSIONS: SSPE remains a diagnostic challenge, and should be considered in the differential diagnosis of hemoptysis of unknown etiology. Further studies are needed to guide anticoagulation decisions in these patients.

Reference #1: WIENER RS, et al. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med. 2011;171:831-7

Reference #2: Stein PD, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006; 354:2317-27

DISCLOSURE: The following authors have nothing to disclose: Ala Eddin Sagar, Farah Kazzaz, Soma Jyothula

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