ElectricPE: The Diagnosis of Pulmonary Embolism: Case Study 4
Jeffrey R. Galvin, M.D. and James J. Choi, B.S.
Peer Review Status: Internally Reviewed
The deep veins from the upper thigh to the ankle could not be
filled with contrast material. Only collateral veins were visualized
in the lower leg. 
Clot was
confirmed in the deep veins of the thigh and more collaterals are
visualized. No clot was visualized in the right iliac veins. Based on
these finding the diagnosis of deep venous thrombosis was made. Clot
was confirmed by computed tomography that was obtained during a
subsequent work up. 
The patient was anticoagulated with heparin based on the venogram
findings. The next day he passed blood per rectum and was found to
have an adenocarcinoma of the colon. The anticoagulation was stopped
and a Greenfield filter was placed in the inferior vena cava to
protect his lungs. The patients tumor was resected and he was sent
home after an uneventful recovery in the hospital.
Two weeks after discharge from the hospital Case #4 developed a
cough, fever and right sided pleuritic chest pain. His chest
radiograph now demonstrated bilateral lower lobe densities that were
not present during his prior admission.
The
diagnosis of pneumonia was made based on the presence of fever, cough
and a mild leukocytosis. The possibility of pulmonary embolus was
dismissed because he was felt to be well protected from emboli by the
Greenfield filter. The patient responded poorly to antibiotics alone
and complained of recurrent bilateral chest pain. As a consequence a
Ventilation/Perfusion scan was obtained.
The perfusion scan shows multiple, bilateral, segmental, perfusion
defects. 
The ventilation scan including the wash-out phase is essentially
normal. 
Case Assessment
This is a classic high probability scan with multiple, wedge-shaped,
perfusion defects that are segmental or greater in size. The lung
ventilates normally in all of these areas.
Case #4 was anticoagulated with complete resolution of his symptoms
1. A Greenfield filter does not work well when it is tipped more that 15 degrees from the axis of the inferior vena cava. You may have noticed when you looked at this abdominal film the first time that this filter is tipped which allows the legs to spread apart. In addition, it is too high in the vena cava. A CT through the area shows that 2 of the legs of the Greenfield actually extend into the R renal vein.
2. Patients with a malignancy, especially adenocarcinomas, may be hypercoagulable and can present with deep venous thrombosis before the malignancy is discovered.
3. The symptoms and signs of pulmonary embolus can mimic those of acute pneumonia.
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