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      An Unusual Presentation of a Massive Pulmonary Embolism with Misleading Investigation Results Treated with Tenecteplase

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          Abstract

          Background. There is no foolproof strategy to identify a pulmonary embolism (PE) in the emergency department, and atypical presentations are common. Negative test results may mislead physicians away from the diagnosis of PE. Objectives. The current report aims to raise awareness of an unusual presentation of massive PE and its diagnosis and management, in the face of limited evidence in the scientific literature. Case Reports. We report the case of a patient with a negative D-Dimer and a negative Computed Tomography contrast angiography of the chest who was diagnosed twenty-seven hours later with a massive PE, as suggested by a bedside echocardiography. The patient was successfully treated with tenecteplase (TNK). Conclusions/Summary. Pulmonary embolism frequently presents atypically and is often a diagnostic challenge. There is limited literature about the treatment of massive PE. Further research on bedside echocardiography for diagnosing PE in unstable patients is warranted. In addition, further study into new thrombolytic agents like tenecteplase in the context of massive and submassive PE is warranted.

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          Multidetector computed tomography for acute pulmonary embolism.

          Paul Stein, Sarah E. Fowler, Lawrence Goodman … (2006)
          The accuracy of multidetector computed tomographic angiography (CTA) for the diagnosis of acute pulmonary embolism has not been determined conclusively. The Prospective Investigation of Pulmonary Embolism Diagnosis II trial was a prospective, multicenter investigation of the accuracy of multidetector CTA alone and combined with venous-phase imaging (CTA-CTV) for the diagnosis of acute pulmonary embolism. We used a composite reference test to confirm or rule out the diagnosis of pulmonary embolism. Among 824 patients with a reference diagnosis and a completed CT study, CTA was inconclusive in 51 because of poor image quality. Excluding such inconclusive studies, the sensitivity of CTA was 83 percent and the specificity was 96 percent. Positive predictive values were 96 percent with a concordantly high or low probability on clinical assessment, 92 percent with an intermediate probability on clinical assessment, and nondiagnostic if clinical probability was discordant. CTA-CTV was inconclusive in 87 of 824 patients because the image quality of either CTA or CTV was poor. The sensitivity of CTA-CTV for pulmonary embolism was 90 percent, and specificity was 95 percent. CTA-CTV was also nondiagnostic with a discordant clinical probability. In patients with suspected pulmonary embolism, multidetector CTA-CTV has a higher diagnostic sensitivity than does CTA alone, with similar specificity. The predictive value of either CTA or CTA-CTV is high with a concordant clinical assessment, but additional testing is necessary when the clinical probability is inconsistent with the imaging results. Copyright 2006 Massachusetts Medical Society.
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            Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis.

            Saurav Chatterjee, Anasua Chakraborty, Ido Weinberg … (2014)
            Thrombolytic therapy may be beneficial in the treatment of some patients with pulmonary embolism. To date, no analysis has had adequate statistical power to determine whether thrombolytic therapy is associated with improved survival, compared with conventional anticoagulation. To determine mortality benefits and bleeding risks associated with thrombolytic therapy compared with anticoagulation in acute pulmonary embolism, including the subset of hemodynamically stable patients with right ventricular dysfunction (intermediate-risk pulmonary embolism). PubMed, the Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases from inception through April 10, 2014. Eligible studies were randomized clinical trials comparing thrombolytic therapy vs anticoagulant therapy in pulmonary embolism patients. Sixteen trials comprising 2115 individuals were identified. Eight trials comprising 1775 patients specified inclusion of patients with intermediate-risk pulmonary embolism. Two reviewers independently extracted trial-level data including number of patients, patient characteristics, duration of follow-up, and outcomes. The primary outcomes were all-cause mortality and major bleeding. Secondary outcomes were risk of recurrent embolism and intracranial hemorrhage (ICH). Peto odds ratio (OR) estimates and associated 95% CIs were calculated using a fixed-effects model. Use of thrombolytics was associated with lower all-cause mortality (OR, 0.53; 95% CI, 0.32-0.88; 2.17% [23/1061] vs 3.89% [41/1054] with anticoagulants; number needed to treat [NNT] = 59) and greater risks of major bleeding (OR, 2.73; 95% CI, 1.91-3.91; 9.24% [98/1061] vs 3.42% [36/1054]; number needed to harm [NNH] = 18) and ICH (OR, 4.63; 95% CI, 1.78-12.04; 1.46% [15/1024] vs 0.19% [2/1019]; NNH = 78). Major bleeding was not significantly increased in patients 65 years and younger (OR, 1.25; 95% CI, 0.50-3.14). Thrombolysis was associated with a lower risk of recurrent pulmonary embolism (OR, 0.40; 95% CI, 0.22-0.74; 1.17% [12/1024] vs 3.04% [31/1019]; NNT = 54). In intermediate-risk pulmonary embolism trials, thrombolysis was associated with lower mortality (OR, 0.48; 95% CI, 0.25-0.92) and more major bleeding events (OR, 3.19; 95% CI, 2.07-4.92). Among patients with pulmonary embolism, including those who were hemodynamically stable with right ventricular dysfunction, thrombolytic therapy was associated with lower rates of all-cause mortality and increased risks of major bleeding and ICH. However, findings may not apply to patients with pulmonary embolism who are hemodynamically stable without right ventricular dysfunction.
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              Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism.

              Stavros Konstantinides, Annette Geibel, Gerhard Heusel … (2002)
              The use of thrombolytic agents in the treatment of hemodynamically stable patients with acute submassive pulmonary embolism remains controversial. We conducted a study of patients with acute pulmonary embolism and pulmonary hypertension or right ventricular dysfunction but without arterial hypotension or shock. The patients were randomly assigned in double-blind fashion to receive heparin plus 100 mg of alteplase or heparin plus placebo over a period of two hours. The primary end point was in-hospital death or clinical deterioration requiring an escalation of treatment, which was defined as catecholamine infusion, secondary thrombolysis, endotracheal intubation, cardiopulmonary resuscitation, or emergency surgical embolectomy or thrombus fragmentation by catheter. Of 256 patients enrolled, 118 were randomly assigned to receive heparin plus alteplase and 138 to receive heparin plus placebo. The incidence of the primary end point was significantly higher in the heparin-plus-placebo group than in the heparin-plus-alteplase group (P=0.006), and the probability of 30-day event-free survival (according to Kaplan-Meier analysis) was higher in the heparin-plus-alteplase group (P=0.005). This difference was due to the higher incidence of treatment escalation in the heparin-plus-placebo group (24.6 percent vs. 10.2 percent, P=0.004), since mortality was low in both groups (3.4 percent in the heparin-plus-alteplase group and 2.2 percent in the heparin-plus-placebo group, P=0.71). Treatment with heparin plus placebo was associated with almost three times the risk of death or treatment escalation that was associated with heparin plus alteplase (P=0.006). No fatal bleeding or cerebral bleeding occurred in patients receiving heparin plus alteplase. When given in conjunction with heparin, alteplase can improve the clinical course of stable patients who have acute submassive pulmonary embolism and can prevent clinical deterioration requiring the escalation of treatment during the hospital stay. Copyright 2002 Massachusetts Medical Society
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                Author and article information

                Journal
                Journal ID (nlm-ta): Case Rep Emerg Med
                Journal ID (iso-abbrev): Case Rep Emerg Med
                Journal ID (publisher-id): CRIEM
                Title: Case Reports in Emergency Medicine
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 2090-648X
                ISSN (Electronic): 2090-6498
                Publication date (Print): 2015
                Publication date (Electronic): 19 February 2015
                Volume: 2015
                Electronic Location Identifier: 868519
                Affiliations
                1Department of Emergency Medicine, Vancouver General Hospital, University of British Columbia, Room 3300 910, West 10th Avenue, Vancouver, BC, Canada V5Z 1M9
                2Emergency Department, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Avenue, Room B2.117, Montreal, QC, Canada H3G 1A4
                Author notes

                Academic Editor: Ching H. Loh

                Article
                DOI: 10.1155/2015/868519
                PMC ID: 4350959
                PubMed ID: 25789181
                SO-VID: 5137fa9d-61fd-423a-b312-063ab915bd9e
                Copyright © Copyright © 2015 David Migneault et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 28 November 2014
                Date accepted : 10 February 2015
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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