Rare causes of haemoptysis in suspected pulmonary embolism
http://www.100md.com
《英国医生杂志》
1 Department of General Medicine, New Cross Hospital, Wolverhampton WV6 7OQ, 2 Walsgrave Hospital
Correspondence to: M Warburton matthew_karen@sayang.freeserve.co.uk
Introduction
Thoracic aneurysms are rare, estimated at 6 per 100 000 a year.1 In contrast, pulmonary embolism is more common (60 to 70 cases per 100 000 a year).2 We know that "common things occur commonly," and since pulmonary emboli have a considerable mortality associated with them, there is a great temptation to treat before the diagnosis is confirmed. The British Thoracic Society recommends initial investigation with d-dimer assays and, if combined with a high clinical suspicion, treatment with low molecular weight heparins until imaging is available. In this case, however, to have given any kind of anticoagulation might have proved fatal.
The society's guidelines also state that if a pulmonary embolus is ruled out (or thought unlikely) then high resolution or multislice computed tomography is necessary to identify the true nature of the pain.
The clues that pointed this case towards an "atypical" chest pain were the high white cell count; the large level of haemoptysis; no significant hypoxia; no evidence of deep venous thrombosis on clinical examination; and a pain much more severe than would be expected for pulmonary embolism.
This mode of presentation is also somewhat unusual for a thoracic aortic aneurysm in terms of the nature of the pain and the presence of haemoptysis. The location of the aneurysm was such that it was not apparent on the plain chest radiograph. The identification of micro-organisms would suggest an infective aetiology.
We advise to always consider alternative diagnoses of pulmonary embolism if atypical features are present.
Do not automatically treat a suspected pulmonary embolism with heparin; consider other diagnoses first
MB now works at New Cross Hospital, Wolverhampton.
Contributors: All four authors were involved in the treatment of the patient in the case study, and all were involved in writing the paper. MAJ is the guarantor.
Funding: None.
Competing interests: None declared.
References
Bickerstaff LK, Pairolero PC, Hollier LH, Melton LJ, van Peenen HJ, Cherry KJ, et al. Thoracic aortic aneurysms: a population-based study. Surgery 1982;92: 1103-8.
British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58: 470-83.(M S Warburton, senior hou)
Correspondence to: M Warburton matthew_karen@sayang.freeserve.co.uk
Introduction
Thoracic aneurysms are rare, estimated at 6 per 100 000 a year.1 In contrast, pulmonary embolism is more common (60 to 70 cases per 100 000 a year).2 We know that "common things occur commonly," and since pulmonary emboli have a considerable mortality associated with them, there is a great temptation to treat before the diagnosis is confirmed. The British Thoracic Society recommends initial investigation with d-dimer assays and, if combined with a high clinical suspicion, treatment with low molecular weight heparins until imaging is available. In this case, however, to have given any kind of anticoagulation might have proved fatal.
The society's guidelines also state that if a pulmonary embolus is ruled out (or thought unlikely) then high resolution or multislice computed tomography is necessary to identify the true nature of the pain.
The clues that pointed this case towards an "atypical" chest pain were the high white cell count; the large level of haemoptysis; no significant hypoxia; no evidence of deep venous thrombosis on clinical examination; and a pain much more severe than would be expected for pulmonary embolism.
This mode of presentation is also somewhat unusual for a thoracic aortic aneurysm in terms of the nature of the pain and the presence of haemoptysis. The location of the aneurysm was such that it was not apparent on the plain chest radiograph. The identification of micro-organisms would suggest an infective aetiology.
We advise to always consider alternative diagnoses of pulmonary embolism if atypical features are present.
Do not automatically treat a suspected pulmonary embolism with heparin; consider other diagnoses first
MB now works at New Cross Hospital, Wolverhampton.
Contributors: All four authors were involved in the treatment of the patient in the case study, and all were involved in writing the paper. MAJ is the guarantor.
Funding: None.
Competing interests: None declared.
References
Bickerstaff LK, Pairolero PC, Hollier LH, Melton LJ, van Peenen HJ, Cherry KJ, et al. Thoracic aortic aneurysms: a population-based study. Surgery 1982;92: 1103-8.
British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58: 470-83.(M S Warburton, senior hou)