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A 37-year-old female patient presented to the emergency department with a 3-week history of dyspnea, hypoxemia, pleuritic chest pain, and lower limb edema. She had no history of comorbidities and had had two normal pregnancies. There was no family history of thrombosis. An electrocardiogram showed right axis deviation, and blood tests revealed elevated D-dimer levels. A routine chest X-ray showed oligemia in the right hemithorax and engorgement of the left pulmonary artery (Figure 1). Chest CT angiography confirmed the presence of a thrombus in the pulmonary artery trunk and full occlusion of the right segment (Figure 2). The coronal reconstruction shown in Figure 3 elegantly demonstrates the complete lack of pulmonary perfusion in the right lung, together with ipsilateral oligemia. Echocardiography confirmed pulmonary hypertension (systolic pulmonary artery pressure, 80 mmHg) and right ventricular dysfunction. Because of hemodynamic instability, the patient was submitted to thrombolysis with alteplase and started on anticoagulation therapy. Her dyspnea persisted, and she was categorized as New York Heart Association functional class III. After 6 months, she evolved to chronic pulmonary thromboembolic disease. Positron emission tomography and nuclear magnetic resonance imaging were performed to exclude angiosarcoma. At this writing, the patient is under evaluation for thromboendarterectomy.
Figure 1. Thoracic X-ray revealing oligemia in the right hemithorax and engorgement of the left pulmonary artery.
Uma paciente de 37 anos procurou o setor de emergência com história de dispneia, hipoxemia, dor torácica pleurítica e edema nos membros inferiores há três semanas. A paciente não apresentava história de comorbidades e havia tido duas gravidezes normais e sem história familiar de trombose. O eletrocardiograma mostrou desvio do eixo à direita e os testes sanguíneos revelaram níveis de dímero D elevados. Uma radiografia de tórax de rotina mostrou oligoemia no hemitórax direito e ingurgitamento da artéria pulmonar esquerda (Figura 1). A angiotomografia de tórax confirmou a presença de um trombo no tronco da artéria pulmonar e completa oclusão do segmento direito (Figura 2). A reconstrução coronal mostrada na Figura 3 elegantemente demonstra a completa falta de perfusão pulmonar no pulmão direito, associada a oligoemia ipsilateral. A ecocardiografia confirmou hipertensão pulmonar (pressão sistólica da artéria pulmonar = 80 mmHg) e disfunção ventricular direita. Devido à instabilidade hemodinâmica, a paciente foi submetida a trombólise com alteplase e iniciou terapia anticoagulante. A dispneia persistiu, sendo a paciente categorizada como classe funcional III segundo os critérios da New York Heart Association. Seis meses depois, a paciente evoluiu para doença tromboembólica pulmonar crônica. A tomografia por emissão de pósitrons e a ressonância magnética nuclear foram realizadas a fim de excluir o diagnóstico de angiosarcoma. Até o momento, a paciente está sendo avaliada para tromboendarterectomia.
Figura 1. Radiografia de tórax evidenciando oligoemia no hemitórax direito e ingurgitamento da artéria pulmonar esquerda.
