PMC10475506_01
Primary Care CXR: CXR from initial immediate care visit one month prior to emergency department presentation demonstrating bilateral opacities concerning for community acquired pneumonia. Opacities are indicated by the red arrows. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
gr1.jpg
PMC10475506_01_gr1.jpg
fig1
A chest x-ray (CXR) (Fig. 1) demonstrated a significant right upper lobe consolidation concerning for community-acquired pneumonia and she was prescribed levofloxacin for seven days.
CT Pulmonary Angiogram: Saddle pulmonary embolism seen on CT pulmonary angiogram demarcated by the red arrow. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
gr2.jpg
PMC10475506_01_gr2.jpg
fig2
Due to a moderately elevated Well's score of 4.5 (high suspicion for PE and heart rate >100) and markedly elevated d-dimer 5672 ng/mL (normal <500 ng/mL), a computed tomography (CT) pulmonary angiogram was performed which revealed a saddle PE with a large proximal clot burden (modified miller score 16) (Fig. 2).
2D-transthoracic echocardiogram: Echocardiogram demonstrating significant enlargement of the right ventricle secondary to a sub-massive pulmonary embolism. There is an increase in the right ventricle to left ventricle ratio at 1.4 (normal 0.8) seen in panel A. Tricuspid annular plane systolic excursion of 21 mm (normal >=17) indicating normal right ventricle systolic function is demonstrated in panel B.
gr3.jpg
PMC10475506_01_gr3.jpg
fig3
A 2D-transthoracic echocardiogram revealed a left ventricle (LV) ejection fraction of 65%, an increase in the RV to LV ratio at 1.4 (normal 0.8), and normal RV systolic function (tricuspid annular plane systolic excursion 21 mm (normal >=17 mm) (Fig. 3).
Chest CT: Bilateral nodular opacities concerning for miliary tuberculosis seen on chest CT are indicated by the red arrows in the axial view (A) and coronal view (B). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
gr4.jpg
PMC10475506_01_gr4.jpg
fig4
Interestingly, in addition to PE, there were innumerable nodular and patchy tiny areas of consolidations bilaterally concerning for multifocal infection (Fig. 4).