Unmasking the Wolf in Sheep’s Clothing: Atypical Presentation of Pulmonary Embolism as Acute Abdomen - A Case Report1st and Corresponding Author: Dr. Lolwa Al-Khulaifi, Emergency Medicine Resident, Medical Education.Hamad Medical Cooperation.Email: [email protected] Author: Dr. Mohammed Elgassim, Emergency Medicine Resident, Medical Education.Hamad Medical Cooperation.Email: [email protected] Author: Dr. Waleed Salem, Emergency Medicine Senior Consultant, Hamad Medical Education.Email: [email protected]’s contributions: The authors confirm contribution to the paper as followsLiterature review: 1st Author.Draft Manuscript preparation: 1st and 2nd Authors.Draft manuscript revision: 1st, 2nd,and 3rd Authors.Project supervision: 3rd Author.The patient has consented in a written form for the following information to be published and released; written information is provided.Keywords:Pulmonary Embolism (PE), Epigastric pain, Right heart strain, Anticoagulation.Introduction:Pulmonary embolism (PE) is defined as the blockage of the pulmonary artery or its branches by material that was created elsewhere in the body, such as thrombus, tumor, fat, or air [1]. There are multiple risk factors that can provoke the development of PE. There are all combined in one triad called Virchow’s triad, which include venous stasis, endothelial injury, and hypercoagulable status [2,3]. PE is considered one the common diseases and a fatal one too. It is thought to be responsible for 50,000-200,000 deaths yearly [4].The variety of its presenting features can range from no symptoms at all, to sudden death. Current resources consider dyspnea as the most common presenting feature for PE. Other common presentation includes chest pain, hemoptysis, syncope, or symptoms of deep venous thrombosis [5]. However, the uncommon presentation of PE is not well illustrated. And this may lead to misdiagnosis of this fatal disease. Herein, we present this case of one the uncommon presentation of PE in clinical practice.History and physical examination:A 40-year-old previously healthy Sri-Lankan male was referred to the emergency department from a private clinic due to epigastric pain and abnormal ECG, mainly to rule out myocardial infarction. The patient had abdominal pain localized to the epigastric area, sharp in nature, started suddenly today at around 4 hours prior to presentation. The non-radiating, with no exacerbating/alleviating factors. There was no history of chest pain, shortness of breath palpitations, dizziness, or syncope. The patient also denied any additional gastrointestinal or genitourinary symptoms. He had an appendectomy done 10 years back, otherwise he does not suffer from any chronic medical illnesses. His family history was unremarkable. He is smoker and drinks alcohol occasionally with no use of illicit drugs. And lastly, he works as a laundry business and no recent travel history.The ECG that was done in the clinic that raise the suspicion of MI had no changes compared to the ECG done in the emergency department, showing normal sinus rhythm, heart rate of 100, with T- wave inversion in lead V1-V3. No other remarkable findings were found. During his emergency department stay, he was initially calm and not in respiratory distress, with normal vital sings. Then when he was re-examined, vital signs were Temperature: 36.9 °C, Heart Rate: 119 bpm, Respiratory Rate: 27 bpm, Blood Pressure: 147/107, SpO2: 97%. Upon physical examination, the remarkable findings were epigastric tenderness with no obvious peritoneal signs. Cardiovascular and respiratory examinations were normal. In addition, point of care ultrasound (POCUS) was done by a POCUS subspeciality expert and showed normal heart contractility and function, no right ventricular dilation, no pericardial fluid, with normally sized abdominal aorta.Methods:Laboratory and imaging investigation were done to rule out the possibility of MI or a perforated viscus. These included complete blood count, complete metabolic panne, cardiac enzymes (Troponin-T), venous blood gas, chest x-ray (figure 1) and repeat ECG (figure 2). The remarkable results were leukocytosis and Troponin T of 9, then second set of 11. The patient status has progressed further with tachypnea and sweating; however, the pain was less after analgesia. This has prompted the physician to proceed with CT Abdomen to look for a possible perforated viscus. The result of that imaging showed that the visualized lower chest section has features concerning of bilateral pulmonary embolism. The next step after this report was to have an CT pulmonary angiography (figure 3 and 4), that confirmed the presence of bilateral pulmonary artery thromboembolism with right ventricular strain.Conclusion:After the confirmed diagnosis the patient received the therapeutic dose of anticoagulation (enoxaparin) and disposition to medical intensive care unit has been made, where he received thrombolysis. Further workup and observation have been done. The patient’s stay was uneventful, he was stepped down to the medical ward, then discharged home.Discussion:This case presents a diagnostic challenge, initially raising suspicion of myocardial infarction due to epigastric pain and abnormal ECG findings. The patient’s journey underscores the importance of a comprehensive diagnostic approach. The timely utilization of imaging played a pivotal role in steering the diagnostic process. The CT Abdomen, though initially sought to investigate a potential perforated viscus, revealed features concerning bilateral pulmonary embolism. Subsequent confirmation through CT pulmonary angiography provided critical insights into the extent of pulmonary artery thromboembolism. In the management of this case, swift initiation of therapeutic anticoagulation (enoxaparin) and subsequent medical intensive care unit admission for thrombolysis showcased the impact of prompt decision-making on positive patient outcomes.A comprehensive literature review revealed similar cases, emphasizing a 6.7% incidence of pulmonary embolism presenting with abdominal pain [6]. It hypothesizes possible mechanisms that may explain abdominal pain in PE, such as hepatic congestion due to right heart strain, diaphragmatic irritation, and tension on the parietal pleura nerve endings [6-9]. This enhances our understanding of atypical presentations. It is crucial to acknowledge the mortality risk associated with missed or untreated pulmonary embolism, estimated at around 30% [10]. Also, around 70% of misdiagnosed PEs were discovered postmortem [4]. Unfortunately, traditional learning resources often overlook unusual presentations [9]. Therefore, presenting this case contributes to existing literature, urging physicians to consider pulmonary embolism in patients with abdominal pain.The strengths in our case management include effective triaging, considering the patient’s clinical status, and the initial use of POCUS. However, areas for improvement include advocating for a broader initial differential diagnosis and recognizing the potential benefits of serial POCUS examinations.Lastly, this case serves as a reminder of the diagnostic intricacies surrounding pulmonary embolism, particularly its atypical presentations. By incorporating such cases into educational materials, we hope to enhance physician awareness, prompt further research, and ultimately reduce misdiagnosis and mortality rates associated with pulmonary embolism.Key clinical message:This case highlights the importance of implementing a systematic approach and keeping a wide differential when encountering nonspecific symptoms. Along with the other similar cases, here we remind the physicians to have high index of suspicion of PE, especially with uncommon symptoms such as abdominal pain. This realization could lead to a lifesaving decision in clinical practice.References:Rali, P., Gandhi, V., & Malik, K. (2016). Pulmonary embolism. Critical Care Nursing Quarterly, 39(2), 131–138. doi:10.1097/cnq.0000000000000106.Bagot, C. N., & Arya, R. (2008). Virchow and his triad: A question of attribution. British Journal of Haematology, 143(2), 180–190. doi:10.1111/j.1365-2141.2008.07323.Coon, W. W., & Willis, P. W. (1959). Deep venous thrombosis and pulmonary embolism. The American Journal of Cardiology, 4(5), 611–621. doi:10.1016/0002-9149(59)90145-6.Derr, C., Gantner, J., & Keffeler, J. (2013). Pulmonary embolism: An abdominal pain masquerader. Journal of Emergencies, Trauma, and Shock, 6(4), 280. doi:10.4103/0974-2700.120376.Stein, P. D., Terrin, M. L., Hales, C. A., Palevsky, H. I., Saltzman, H. A., Thompson, B. T., & Weg, J. G. (1991). Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest, 100(3), 598–603. doi:10.1378/chest.100.3.598.Israel, H. L., & Goldstein, F. (1957). The varied clinical manifestations of pulmonary embolism. Annals of internal medicine, 47(2), 202–226. doi:10.7326/0003-4819-47-2-202.Kounis N. G. (1979). Pulmonary embolism with neurological and abdominal manifestations. The Practitioner, 223(1333), 115–116.Gorham, L. W. (1961). A study of pulmonary embolism. Archives of Internal Medicine, 108(2), 189. doi:10.1001/archinte.1961.03620080021003.Han, Y., & Gong, Y. (2019). Pulmonary embolism with abdominal pain as the chief complaint. Medicine, 98(44). doi:10.1097/md.0000000000017791.Carson, J. L., Kelley, M. A., Duff, A., Weg, J. G., Fulkerson, W. J., Palevsky, H. I, Terrin, M. L. (1992). The clinical course of pulmonary embolism. New England Journal of Medicine, 326(19), 1240–1245. doi:10.1056/nejm199205073261902.Images:
