EJINME-02756; No of Pages 2 European Journal of Internal Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Pulmonary embolism, where are the thrombi? Natalia Lorenzo, Jorge Andrés Restrepo, Rio Aguilar ⁎ Department of Cardiology, Hospital Universitario de La Princesa, Calle Diego de León, 62, 28006 Madrid, Spain
a r t i c l e
i n f o
Article history: Received 20 May 2014 Received in revised form 22 June 2014 Accepted 25 June 2014 Available online xxxx Keywords: Pulmonary embolism Cholecystitis Bile
1. Indication A 44-year-old man was admitted to the emergency service because of an acute onset of dyspnoea and unspecific abdominal pain during the previous 4 days. His medical history was unremarkable. He was in sinus tachycardia, with fever and hypoxemia. Chest X-ray and blood tests were normal except from discrete hyperbilirubinemia. While he was in the emergency unit, he suffered acute respiratory and hemodynamical failure and he was admitted to the intensive care unit. The patient suffered a first episode of cardiac arrest and transesophageal echocardiography was performed. It showed severe right ventricle dilatation (Fig. 1, panel A) and dysfunction with high pulmonary pressure. Massive pulmonary thromboembolism was suspected but main pulmonary artery and its major branches were free of thrombi (panel B). Due to hemodynamic instability thorax CT scan was not possible. New cardiac arrest in asystole occurred and the patient died after 60 min of resuscitation manoeuvres. D-Dimer level was requested, however, results were only available after the patient died (it was ten times over the normal limit). The post-mortem study diagnosed acute cholecystitis due to Collinsella aerofaciens, with massive bile emboli to the small- and medium-sized branches of the pulmonary arteries diffusely throughout both lungs (panels C & D).
Fig. 1. Transesophageal echocardiography showing severe right ventricle dilatation (panel A), and pulmonary artery and its main branches free of thrombi (panel B). Bile emboli to the small and medium-sized pulmonary arteries (panel C). Cholesterol crystals in the pulmonary circulation (panel D).
What is the diagnosis?
⁎ Corresponding author. Tel.: +34 655080531. E-mail address: [email protected] (R. Aguilar).
http://dx.doi.org/10.1016/j.ejim.2014.06.024 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Lorenzo N, et al, Pulmonary embolism, where are the thrombi?, Eur J Intern Med (2014), http://dx.doi.org/10.1016/ j.ejim.2014.06.024
2
N. Lorenzo et al. / European Journal of Internal Medicine xxx (2014) xxx–xxx
2. Diagnosis There are less than 20 cases reported of bile pulmonary embolism, although subclinical embolism may occur more commonly [1]. Almost all of these cases are related to trauma or medical manipulations [2]; however, this is the first case report of cholecystitis being diagnosed after shock due to pulmonary cholesterol emboli. Bile enters the systemic circulation through an abnormal fistulous communication between the biliary tree and the venous hepatic system. Bilhemia is thought to occur only in the presence of increased intrabiliary pressure, because of obstruction distal to the level of the fistula as a result of the underlying pathology, for example, a tumour or a stone [3].
Conflict of interests The authors state that they have no conflicts of interest. References [1] Morentin B, Aguilera B, Portugal V, Suárez-Mier MP, Arnaiz JF. Non traumatic fatal bile pulmonary embolism following lithiasic cholecystitis. Rev Esp Enferm Dig 2007;99:730–41. [2] Siddiqui J, Jaffe PE, Aziz K, Forouhar F, Sheppard R, Covault J, et al. Fatal air and bile embolism after percutaneous liver biopsy and ERCP. Gastrointest Endosc 2005;61:153. [3] Kihira T, Konishi T, Shiraishi T, Yatani R, Nakano T. Fatal bile pulmonary embolism following percutaneous transhepatic cholangiodrainage: case report and literature review. Angiology 1993;15:725–30.
Please cite this article as: Lorenzo N, et al, Pulmonary embolism, where are the thrombi?, Eur J Intern Med (2014), http://dx.doi.org/10.1016/ j.ejim.2014.06.024
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
Pulmonary embolism, where are the thrombi? Natalia Lorenzo, Jorge Andrés Restrepo, Rio Aguilar ⁎ Department of Cardiology, Hospital Universitario de La Princesa, Calle Diego de León, 62, 28006 Madrid, Spain
a r t i c l e
i n f o
Article history: Received 20 May 2014 Received in revised form 22 June 2014 Accepted 25 June 2014 Available online xxxx Keywords: Pulmonary embolism Cholecystitis Bile
1. Indication A 44-year-old man was admitted to the emergency service because of an acute onset of dyspnoea and unspecific abdominal pain during the previous 4 days. His medical history was unremarkable. He was in sinus tachycardia, with fever and hypoxemia. Chest X-ray and blood tests were normal except from discrete hyperbilirubinemia. While he was in the emergency unit, he suffered acute respiratory and hemodynamical failure and he was admitted to the intensive care unit. The patient suffered a first episode of cardiac arrest and transesophageal echocardiography was performed. It showed severe right ventricle dilatation (Fig. 1, panel A) and dysfunction with high pulmonary pressure. Massive pulmonary thromboembolism was suspected but main pulmonary artery and its major branches were free of thrombi (panel B). Due to hemodynamic instability thorax CT scan was not possible. New cardiac arrest in asystole occurred and the patient died after 60 min of resuscitation manoeuvres. D-Dimer level was requested, however, results were only available after the patient died (it was ten times over the normal limit). The post-mortem study diagnosed acute cholecystitis due to Collinsella aerofaciens, with massive bile emboli to the small- and medium-sized branches of the pulmonary arteries diffusely throughout both lungs (panels C & D).
Fig. 1. Transesophageal echocardiography showing severe right ventricle dilatation (panel A), and pulmonary artery and its main branches free of thrombi (panel B). Bile emboli to the small and medium-sized pulmonary arteries (panel C). Cholesterol crystals in the pulmonary circulation (panel D).
What is the diagnosis?
⁎ Corresponding author. Tel.: +34 655080531. E-mail address: [email protected] (R. Aguilar).
http://dx.doi.org/10.1016/j.ejim.2014.06.024 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Lorenzo N, et al, Pulmonary embolism, where are the thrombi?, Eur J Intern Med (2014), http://dx.doi.org/10.1016/ j.ejim.2014.06.024
2
N. Lorenzo et al. / European Journal of Internal Medicine xxx (2014) xxx–xxx
2. Diagnosis There are less than 20 cases reported of bile pulmonary embolism, although subclinical embolism may occur more commonly [1]. Almost all of these cases are related to trauma or medical manipulations [2]; however, this is the first case report of cholecystitis being diagnosed after shock due to pulmonary cholesterol emboli. Bile enters the systemic circulation through an abnormal fistulous communication between the biliary tree and the venous hepatic system. Bilhemia is thought to occur only in the presence of increased intrabiliary pressure, because of obstruction distal to the level of the fistula as a result of the underlying pathology, for example, a tumour or a stone [3].
Conflict of interests The authors state that they have no conflicts of interest. References [1] Morentin B, Aguilera B, Portugal V, Suárez-Mier MP, Arnaiz JF. Non traumatic fatal bile pulmonary embolism following lithiasic cholecystitis. Rev Esp Enferm Dig 2007;99:730–41. [2] Siddiqui J, Jaffe PE, Aziz K, Forouhar F, Sheppard R, Covault J, et al. Fatal air and bile embolism after percutaneous liver biopsy and ERCP. Gastrointest Endosc 2005;61:153. [3] Kihira T, Konishi T, Shiraishi T, Yatani R, Nakano T. Fatal bile pulmonary embolism following percutaneous transhepatic cholangiodrainage: case report and literature review. Angiology 1993;15:725–30.
Please cite this article as: Lorenzo N, et al, Pulmonary embolism, where are the thrombi?, Eur J Intern Med (2014), http://dx.doi.org/10.1016/ j.ejim.2014.06.024
