The Virtual Hospital: ElectricPE: The Diagnosis of Pulmonary Embolism: Weight Loss and Hemoptysis

ElectricPE: The Diagnosis of Pulmonary Embolism: Case Study 26

Weight Loss and Hemoptysis

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

This case was a 56 year old female with a 40 pack year history of smoking who was in good health except for unintended weight loss of 20 pounds over the 6 months. 3 days prior to admission she consulted her local physician because of pain and swelling in her left lower extremity. At the time of admission to this hospital she was mildly dyspneic on exertion and had coughed up a small amount of red tinged sputum. Her arterial blood gases showed a respiratory alkalosis and hypoxia: PH 7.47, PCO2 33, PO2 53 on room air

The chest x-ray showed a density in the superior segment of the left lower lobe. The differential diagnosis at that time was either consolidation or a mass lesion.

A CT through the superior segment of the left lower lobe confirmed a pleural based density. In addition, multiple other areas of density were noted in the periphery of both lungs. This study suggested the possibility of multiple pulmonary infarcts.

Mediastinal images from that chest CT showed multiple enlarged lymph nodes in the mediastinum. Further workup was postponed until the question of pulmonary embolus was settled.

A V/Q scan showed multiple perfusion defects with relatively normal ventilation in most areas. This was read as high probability for pulmonary embolus. She was anticoagulated with heparin and discharged on coumadin.

Two weeks later she was re-admitted to the hospital with new swelling in her right extremity and recurrent hemoptysis. A repeat V/Q scan demonstrated multiple new perfusion defects consistent with multiple new emboli. A Greenfield filter was placed in the inferior vena cave to protect her lungs.

Two days later she was admitted to the medical intensive care unit with sudden shortness of breath, hypotension and increasing leg edema. A CT scan through the new vena cava filter showed that it had clotted and that thrombus now extended above the filter.

A needle biopsy of her mediastinal lymph nodes revealed adenocarcinoma of unknown etiology.

Case Assessment
This is a 56 year old female smoker who presented with subacute weight loss, left leg swelling, hemoptysis, dyspnea on exertion , respiratory alkalosis and a mild leukocytosis.

1. Patients with adenocarcinomas may present with deep venous thrombosis that is difficult to control by the usual means.

2. Follow-up V/Q scans are useful when trying to assess new symptoms in patients with known pulmonary emboli.

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