Answer to #FridayImageChallenge

Great case and write-up below by: Drs. Allison Lange + Anurag Mehta (@anuragmehta09)

37yo previously healthy man presented with pleuritic chest pain, subjective SOB, hemoptysis. Found to be tachycardic to the 130s with EKG showing sinus tach, tachypneic to the mid 20s, BP 120s systolic on arrival. CXR with Westermarks sign and Hamptons hump.

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You were correct! We see BOTH Westermark sign + Hampton hump

Common findings on CXR:
Westermark sign: sensitivity: ~14% , specificity: ~92%  dilation of the pulmonary artery proximal to an embolism with collapse of distal vessels (creating focal hyperlucency), the theory behind the sign is either obstruction of the pulmonary artery or distal vasoconstriction in hypoxic lung.

Hampton hump sensitivity: ~22% specificity: ~82% a dome-shaped, pleural-based opacification in the lung most commonly due to pulmonary embolism and lung infarction (it can also result from other causes of pulmonary infarction (e.g. vascular occlusion due to angioinvasive aspergillosis). While a pulmonary artery embolism is expected to result in a wedge-shaped infarction, the expected apex of this infarction may be spared because of bronchial arterial circulation in this part, leading to the characteristic rounded appearance of a Hampton hump.

Fleischner Sign is a prominent central artery that can be caused either by pulmonary hypertension that develops or by distension of the vessel by a large pulmonary embolus. Seen with massive PEs.

A CT was done with findings:

Left Sided Pulmonary Embolismuntitled

Right Sided Pulmonary Embolism
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Enlarged RV w/ septal flattening
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Bedside echo revealed right heart strain. Started on heparin gtt and admitted to MICU.

From PIOPED II study:

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EKG– signs of right heart strain: classically S1Q3T3 pattern, right axis deviation, p pulmonale

CT
Acute pulmonary thrombo-emboli can occasionally be detected on non-contrast chest CT as intraluminal hyperdensities 12.

CT pulmonary angiography (CTPA) will show filling defects within the pulmonary vasculature with acute pulmonary emboli. When observed in the axial plane this has been described as the polo mint sign. The central filling defect from the thrombus is surrounded by a thin rim of contrast, appearing like the popular sweet, the polo mint.

Echo: will see evidence of RV strain including systolic septal bowing and McConnells sign.

McConnell’s sign Echocardiographic pattern of RV dysfunction consisting of akinesia of the mid free wall but normal motion at the apex. 77% sensitivity and 94% specificity for diagnosis of pulmonary embolism.

Acute workup of PEuntitled

Treatment of acute PE
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Sources:
PIOPED II study
NEJM Acute Pulmonary Embolism 2010
Radiopaedia