fat embolism syndrome is a unique clinical condition in which circulating fat droplets lead to multisystem dysfunction . absence of long bone fracture in our patient , along with presence of a cardiac condition , chronic oral anticoagulant therapy , and alleged history of convulsions prior to fall , lessened clinical suspicion for fes . a 38-year - old man fell from his bed , following sudden convulsive movements , and sustained injury to his right shoulder and right hip . he had undergone mitral valve replacement 11 years ago for rheumatic heart disease with mitral valve regurgitation , thus was on penicillin prophylaxis and oral anticoagulant ( acenocoumarol 2 mg / day ) . in a local hospital , he developed shortness of breath and giddiness , and was referred to our hospital . in the casualty , 13 h after his fall , the patient was febrile ( 38.3c ) with a pulse rate of 128 beats min ( bpm ) , and was breathing at 32 bpm . radiographs confirmed comminuted fractures of the head of right humerus and neck of right femur . computed tomography ( ct ) brain was normal and two - dimensional ( 2d ) echocardiography revealed a well - functioning prosthetic mitral valve . the patient was shifted to critical care unit ( ccu ) for further management , where petechiae were noticed in the axillae and upper trunk . initially , on bilevel positive airway pressure , patient was intubated on the 2 day in ccu ( about 40 h after trauma ) and ventilated in view of increasing respiratory insufficiency and deterioration of sensorium . crepitations on auscultation , frothy secretion in the endotracheal tube , and serial chest x - rays [ figure 1 ] showing progressive bilateral infiltrations suggested pulmonary edema . chest x - ray on ( a ) admission and ( b ) 2 day in critical care unit ( ccu ; bilateral infiltrations ) ; prosthetic mitral valve ( arrow ) oxygenation improved with pressure controlled ventilation with assist control . supportive therapy included diuretics , antiepileptics , corticosteroids , antibiotics , nutrition , hydration , and calcium supplementation . ventilatory support was weaned over next 6 days and trachea was extubated . during this period , he subsequently underwent open reduction and internal fixation for fractured head of right humerus and bipolar hemiarthroplasty for fractured neck of right femur . although the first clinical description of fes dates back to 1873 , its diagnosis remains a challenge for clinicians . after an asymptomatic period of 12 - 72 h , few patients develop a triad of lung , brain , and skin involvement known as fes . features of multisystem dysfunction due to either ( 1 ) mechanical obstruction of capillaries by fat emboli , or ( 2 ) production of toxic free fatty acids by hydrolysis of fat occurs predominantly ( 95% ) after major trauma . only 1 - 3% of patients with a single long bone fracture may develop the syndrome , while it may be seen in up to a third of patients with bilateral femoral fractures . fes following fracture of femoral neck or humeral head , as is described in our case report , is highly uncommon . incidence of 0.06% of fes following unilateral fracture of neck of femur was reported , while the incidence was too low to calculate with isolated fractures of the pelvis , ribs , humerus , radius , or ulna . our differential diagnoses were heart failure , pulmonary thrombembolism , neurogenic pulmonary edema , alveolar hemorrhage , and fes . our patient had undergone mitral valve replacement and was on long - term anticoagulant therapy . alleged history of convulsions prompted thorough neurological investigation , including electroencephalography , but could not highlight a cause of the alleged convulsions prior to fall . intracranial bleed or alveolar hemorrhage , as a complication of chronic anticoagulant therapy , was considered . gurd and wilson published the most widely accepted guideline for the diagnosis of fes in 1974 . modified gurd and wilson 's criteria requires at least one major and at least four minor signs for diagnosis [ table 1 ] . schonfeld et al . , incorporated assessment of oxygenation with abg in their scoring system [ table 2 ] . a cumulative score these criteria , however , are not the gold standard for diagnosis . modified gurd and wilson 's criteria reddish - brown nonpalpable petechiae these petechiae , due to embolization of small dermal capillaries leading to extravasation of erythrocytes , occur in only 20 - 50% of patients and resolve quickly . they are virtually diagnostic in the right clinical setting . as per modified gurd and wilson 's criteria [ table 1 ] , three major ( petechiae , respiratory insufficiency , and cerebral involvement ) and four minor criteria ( tachycardia , fever , > 20% fall in hemoglobin ( hb ) level from 12.2 to 9.2 g dl , and increase in erythrocyte sedimentation rate ( esr ) from 21 to 74 mm h ) were satisfied in our patient . possible beneficial effects of corticosteroids include stabilization of the pulmonary capillary membrane , thus reducing interstitial edema , blunting the inflammatory response , stabilizing complement system activation , and retarding platelet aggregation . heparin is known to clear lipemic serum by stimulating lipase activity . without specific tests and validated clinical criteria , diagnosis of fes is challenging . one should uphold a high degree of suspicion in spite of lesser fractures not usually associated with fes . although most patients recover fully , a mortality of 5 - 15% has been reported .
fat embolism syndrome is a rare clinical condition associated with trauma , particularly of long bones . 
 fes after fracture of neck of femur or head of humerus is uncommon . 
 we report a case of fes following fracture in neck of femur and head of humerus in a man with history of mitral valve replacement , on long - term oral anticoagulant therapy , with an alleged history of convulsions . 
 our dilemma in clinical diagnosis is discussed .