Case 4
A 15-year-old female (BMI 39.73 kg/m2), presented with
sudden onset of shortness of breath and chest pain resulting in a
syncopal episode. Patient had history of acne treated with isotretinoin
and COC (norgestimate 0.25 mg - ethinyl estradiol 35 mcg) for 5 months
Chest CTA evaluation revealed saddle pulmonary embolism (Figure 4a and 4
b). Echocardiogram showed moderate to severe right ventricular
enlargement with severe decrease in systolic function. Due to severity
of PE with cardiovascular compromise, systemic thrombolysis with tissue
plasminogen activator (tPA) was initiated at 0.05 mg/kg/hr along with
unfractionated heparin at 10 units/kg/hr. Continuous dose tPA was
discontinued and a bolus of tPA at 0.5 mg/kg given over 2 hr due to
worsening hypotension. Patient cardiovascular condition improved and
repeat chest CTA revealed decreased clot burden in the pulmonary
arteries. Patient completed 3 months of oral anticoagulation with
Rivaroxaban. Repeat echocardiogram and CTA showed normalization of her
right ventricular systolic function and PE respectively.
Thrombophilia testing after completion of anticoagulation revealed
slightly elevated fibrinogen (585 mg/dL; reference range 200-500 mg/dL)
with an elevated D-dimer (789 ng/mL; reference range ≤ 500 ng/mL).
Patient was encouraged to lose weight and will continue close follow up
due to concern of recurrent thrombosis in the setting of elevated
D-dimers.