The Virtual Hospital: ElectricPE: The Diagnosis of Pulmonary Embolism: Multiple Myeloma

ElectricPE: The Diagnosis of Pulmonary Embolism: Case Study 13

Multiple Myeloma

Jeffrey R. Galvin, M.D. and James J. Choi, B.S.
Peer Review Status: Internally Reviewed

This case is a 51 year old male with known multiple myeloma who returned for his third course of chemotherapy. During the admissions history and physical the patient reported a one week history of left posterior pleuritic chest pain that felt better when he rubbed the area with his hand. He had dyspnea on exertion but not at rest. He denied cough, fever, or hemoptysis. He also reported an episode of left lower extremity pain that began 3 weeks ago. The pain has decreased but the swelling has persisted.

His arterial blood gases on admission were PH 7.45 Pco2 33 Po2 64 He had a low grade temperature 37.9

The chest x-ray showed a pleural based density in the left costophrenic angle and a linear density in the posterior aspect of the left lower lobe.

The perfusion scan showed an area of decreased perfusion in the posterior aspect of the left lower lobe that matched the area of infiltrate in the left lower lobe on the chest radiograph.

The ventilation scan showed decreased ventilation in the posterior aspect of the left lower lobe.

This V/Q scan demonstrates a single area of decreased perfusion that matches an area of parenchymal abnormality on the chest x-ray. This should be categorized as an indeterminate scan. The final impression at the time was low probability.

Based on the reading of the V/Q scan the clinicians shifted their focus from the chest and decided to investigate the patients leg pain. A venogram was ordered.

The venogram shows a clot in the deep venous system just above the knee. Since the clinical team was ambivalent about anticoagulating a patient with thrombus in the mid and lower leg, a pulmonary arteriogram was ordered.

The pulmonary arteriogram demonstrated clots in multiple arteries leading to the left lower lobe.

Case Assessment
This 51 year old male presents with classic symptoms and findings of pulmonary embolus: lower extremity pain and swelling, pleuritic chest pain, dyspnea on exertion, respiratory alkalosis, hypoxemia, and rales in the left lower lobe.

1. An indeterminate V/Q scan is non-diagnostic and not synonymous with low probability. (REFERENCE) Further workup is needed to rule out a pulmonary embolus.

2. Although the chest radiograph may be normal in the first few hours after a pulmonary embolus , the majority of patients with a pulmonary embolus will present with an abnormal chest x-ray. (REFERENCE) The current films shows a classic HamptonÕs Hump in the left costophrenic angle. (A HamptonÕs Hump is a pleural based density with a convex surface pointing towards the hilum.)

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