Pulmonary embolism in children is a rare, but potentially life threatening condition. The clinical characteristics overlap with conditions more frequent in children and can mislead the diagnosis.
We report a case of a 15yearold girl who presented to our emergency department with a one week history of progressive dyspnea, initially on exertion and then at rest, associated with chest pain and palpitations. Two months before she had started treatment for acne with oral contraceptive. Physical examination was unremarkable, except for tachypnea and tachycardia. No deep venous thrombosis was evident on physical examination. Lab results demonstrated a normal troponin levels but elevated ddimer 4554ngmL and hypoxia in arterial blood gas analyses. Global clotting times aPTT and PT were normal. ECG showed a Q wave and an inverted T wave in lead III. Mild right atrial and ventricular dilation, right ventricular hyperkinesia and pulmonary hypertension SPAP 55mmHg were the main findings on echocardiogram. High resolution multidetector computed tomographic angiography revealed an extensive thrombus in right main pulmonary artery and a smaller thrombus in left main pulmonary artery extending to lobar and segmental arteries. The girl started enoxaparin and warfarin with rapid resolution of symptoms and increasing physical capacity. Posterior lab workup showed an elevated total cholesterol level 214mgdL, lipoprotein a 52mgdL and IgM anticardiolipin 19UImL. She is heterozygous for Factor V Leiden and for MTHFR mutation.
This association of risk factors explains the severity of the case. High index of suspicion is needed for the diagnosis of pulmonary embolism.