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A deadly cause of syncope

      A 64-year-old woman of good past health presented to the emergency department with syncope. She had upper respiratory symptoms and dizziness followed by worsening exertional dyspnea and palpitation for 2 days. She then developed sudden lightheadedness and transient loss of consciousness. She denied any chest pain. Physical examination found normal blood pressure and pulse, oxygen saturation 94% in ambient air, elevated jugular venous pressure and bilateral ankle edema. A parasternal heave and a grade 2/6 pansystolic murmur at lower left sternal border were noted. Electrocardiography showed left axis deviation. Arterial blood gas confirmed hypoxia and uncompensated respiratory alkalosis. A chest X-ray was taken (Fig. 1).
      Figure thumbnail gr1
      Fig. 1Erect chest radiograph shows dilated right pulmonary artery with abrupt cutoff and downstream oligemia.
      What is the diagnosis?

      Diagnosis: massive pulmonary embolism

      Posterior–anterior radiography of the chest showed dilated pulmonary arteries and abrupt cutoff, most evident at right lower branch (Westermark sign). Subsequent computer tomography pulmonary angiogram confirmed bilateral extensive pulmonary emboli. Though the chest X-ray is abnormal in 80% of patients with pulmonary embolism (PE), highly specific features such as Westermark sign or Hampton's hump occur infrequently [
      • Manganelli D.
      • Palla A.
      • Donnamaria V.
      • Giuntini C.
      Clinical features of pulmonary embolism. Doubts and certainties.
      ]; clinicians must be alert to them, especially in populations where PE is less prevalent, e.g. Chinese [
      • Liu H.S.
      • Kho B.C.
      • Chan J.C.
      • Cheung F.M.
      • Lau K.Y.
      • Choi F.P.
      • et al.
      Venous thromboembolism in the Chinese population—experience in a regional hospital in Hong Kong.
      ].
      Sustained hypotension defines massive PE [
      • Jaff M.R.
      • McMurtry M.S.
      • Archer S.L.
      • Cushman M.
      • Goldenberg N.
      • Goldhaber S.Z.
      • et al.
      Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.
      ]. Intravenous thrombolysis should be rapidly administered without confirmatory imaging in the absence of contraindications to reestablish pulmonary blood flow. Opinions vary with regard to the role of thrombolytics in other situations, such as right ventricular dysfunction on echocardiography, or elevated troponin. In this case, the patient recovered uneventfully with lifelong anticoagulation; no precipitating cause was identified.

      Conflict of interest

      The authors report no conflict of interests regarding this work.

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