Successful treatment of massive pulmonary embolism with rescue fibrinolysis in young patient with homocystinemia – case report
Journal
Serbian Journal of Experimental and Clinical Research
Date Issued
2020-10-01
Author(s)
Lazarova, Emilija
DOI
10.2478/sjecr-2020-0064
Abstract
Pulmonary embolism (PE) is the most frequently missed diag-
nosis in the urgent clinical department with serious consequences.
Patients with unprovoked PE have increased risk of recurrent PE.
Approximately 5 to 8% of PE patients have inherited thrombo-
philias. A solated homocystinemia is a rare cause of unprovoked
acute pulmonary embolism. Timely diagnosis and proper treat-
ment can prevent complications, costs and mortality and provide
patient better quality of life. We are presenting a 42-year-old
woman was admitted to our emergency department with the first
episode of severe dyspnea and chest pain. She had no history of
previous cardiovascular or respiratory disease and no history of
previous pulmonary embolism (PE) or deep vein thrombosis
(DVT). Urgent echocardiography showed indirect signs of pul-
monary embolism which was confirmed by the pulmonary artery
CT angiography performed one day after the patient’s admission.
After two days of heparin infusion, she developed a hemodynamic
instability with cardiogenic shock and was treated successfully
with fibrinolysis. After the clinical stabilization, she was put on the
rivaroxaban therapy, which was recommended for additional six
months. The thrombophilia profile was done two weeks after stop-
ping the therapy with rivaroxaban. The thrombophilia panel came
back positive for high levels of homocysteine (67 μmol/L), with
other thrombophilia results within normal limits. The patient was
stable during the follow-up period. Pulmonary embolism should
be always suspected in younger patients with acute severe dysp-
nea even without provocable risk factors. High suspicion level
and fast diagnosis are lifesaving. In younger patients presented
with unprovoked pulmonary embolism, clinicians should consider
inherited prothrombotic factors and homocystinemia as a poten-
tial cause. Rescue fibrinolysis is a lifesaving therapy in hemody-
namic worsening in intermediate high-risk PE patients. A longer
anticoagulation therapy should be considered in these cases with
novel oral anticoagulants that are recommended as safer and su-
perior therapy.
nosis in the urgent clinical department with serious consequences.
Patients with unprovoked PE have increased risk of recurrent PE.
Approximately 5 to 8% of PE patients have inherited thrombo-
philias. A solated homocystinemia is a rare cause of unprovoked
acute pulmonary embolism. Timely diagnosis and proper treat-
ment can prevent complications, costs and mortality and provide
patient better quality of life. We are presenting a 42-year-old
woman was admitted to our emergency department with the first
episode of severe dyspnea and chest pain. She had no history of
previous cardiovascular or respiratory disease and no history of
previous pulmonary embolism (PE) or deep vein thrombosis
(DVT). Urgent echocardiography showed indirect signs of pul-
monary embolism which was confirmed by the pulmonary artery
CT angiography performed one day after the patient’s admission.
After two days of heparin infusion, she developed a hemodynamic
instability with cardiogenic shock and was treated successfully
with fibrinolysis. After the clinical stabilization, she was put on the
rivaroxaban therapy, which was recommended for additional six
months. The thrombophilia profile was done two weeks after stop-
ping the therapy with rivaroxaban. The thrombophilia panel came
back positive for high levels of homocysteine (67 μmol/L), with
other thrombophilia results within normal limits. The patient was
stable during the follow-up period. Pulmonary embolism should
be always suspected in younger patients with acute severe dysp-
nea even without provocable risk factors. High suspicion level
and fast diagnosis are lifesaving. In younger patients presented
with unprovoked pulmonary embolism, clinicians should consider
inherited prothrombotic factors and homocystinemia as a poten-
tial cause. Rescue fibrinolysis is a lifesaving therapy in hemody-
namic worsening in intermediate high-risk PE patients. A longer
anticoagulation therapy should be considered in these cases with
novel oral anticoagulants that are recommended as safer and su-
perior therapy.
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