Pulmonary Vascular Disease: Student/Resident Case Report Poster - Pulmonary Vascular Disease I |

Pulmonary Embolism and Hyperthyroidism: A Rare Association FREE TO VIEW

Bilal Lashari, MD; Zahra Qamar, MD; Irfan Ahsan, MD; Rajesh Patel, MD
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Abington Jefferson Health, Abington, PA

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

Chest. 2016;150(4_S):1213A. doi:10.1016/j.chest.2016.08.1322
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease I

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: Unprovoked PE remains diagnostic dilemma in most patients. Despite technological advances the reasons for development of an unprovoked VTE remain elusive. We present a patient with an unprovoked Pulmonary embolism with the incidental finding of a rare association.

CASE PRESENTATION: A 46 year old man with no past medical history, or established primary care presented with dyspnea on exertion and calf pain of one week duration. His symptoms begun insidiously with progressive exertional dyspnea for one week to the point where he had difficulty going up a flight of stairs without getting short of breath. He worked as a salesperson and frequently drove in the tristate area each week for work and recolleced a planned weight loss of 40 lbs. In the ER he was found to be hypoxic with an irregular heart rhythm and an otherwise unremarkable exam. He was found to have an new Atrial Fibrillation on an EKG and elevated d-dimers (718 ng/mL). A CT Chest with PE protocol showed a non occlusive saddle embolism, and a Venous ultrasonogram of the lower extremities was negative. He was subsequently started on a therapeutic dose of unfractionated Heparin infusion. Laboratory data showed a TSH of <0.01 UIU/mL, free T3 of 10 and T4 of 14, establishing a diagnosis of Hyperthyroidism. He was started on Metoprolol and Methimazole and discharged with low molecular weight heparin anticoagulation with a pending outpatient hypercoagulability and weight loss workup.

DISCUSSION: Venous thromboembolism (VTE) includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). Over last decade, bedside genetic abnormality and malignancy, multiple risk factors have been shown to be associated with venous thromboembolism. Hyperthyroidism, is one such association. A recent prospective study from taiwan, involving 53,418 patients has established a 2.3 time increased risk of VTE in patients with a decreased TSH over a 5 year period after adjusting for confounding variables. There have been scattered reports of VTE associated with patients in a clinical thyroid storm, however, these are seen as complications of the thyroid disease and not a silent association. The exact pathogenesis of pulmonary embolism in hyperthyroidism is not known.

CONCLUSIONS: In patients with an unprovoked PE, current guidelines highlight treatment in favor of diagnostic workup with treatment now favoring long term anticoagulation. In our opinion, thyroid workup should be included in assessment of patients with unprovoked pulmonary embolism, if no other causes are identified.

Reference #1: Lin HC, Yang LY, Kang JH. Increased risk of pulmonary embolism among patients with hyperthyroidism: Afive-year follow-up study. J Thromb Haemost. 2010;8:2176-81

Reference #2: Grine S, Charfi N, Kamoun M, et al. Hyperthyroidism: A rare cause of pulmonary embolism: Report of two cases. Indian Journal of Endocrinology and Metabolism. 2013;17(6):1104-1107. doi:10.4103/2230-8210.122640.

DISCLOSURE: The following authors have nothing to disclose: Bilal Lashari, Zahra Qamar, Irfan Ahsan, Rajesh Patel

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