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.