Pulmonary embolism

Abstract

Editor-I read with interest 'Lesson of the month 1: A rare adverse reaction between flucloxacillin and paracetamol', published in March's Clinical Medicine , and write with a similar case seen recently in our institution, to further highlight this issue. In addition, although the diagnostic test of choice (urinary organic acids) was unavailable locally we were able to confirm the diagnosis by liaising with another hospital laboratory within our region. An 80-year-old patient with left leg cellulitis and a nondrainable calf abscess, requiring a 3-week course of intravenous flucloxacillin, developed marked hypokalaemia and was found to have a severe, high anion-gap metabolic acidosis (pH 7.16, bicarbonate 7.4 mmol/L, base excess-22.4 mmol/L, serum anion gap 30 mmol/L), without acute kidney injury. Pyroglutamic acidosis was suspected and flucloxacillin and paracetamol were discontinued, and N-acetylcysteine was administered. The acidosis resolved over the course of several days. Urinary organic acid testing was performed at another hospital in the region, showing grossly increased levels of pyroglutamic acid, which had resolved when a repeat specimen was sent 9 days later. ■

Leg massage during pregnancy with unrecognized deep vein thrombosis could be life threatening: a case report

“…Due to sudden onset of dyspnea, consciousness alteration and cardiovascular collapse during massage manipulation of the patient's leg, which was later proven to have pulmonary embolism and deep vein thrombosis, it is reasonable to conclude that the patient had undetected preexisting deep vein thrombosis, which was mechanically dislodged by the massage and travelled massively to both lungs, leading to a life threatening condition. However, differentiation from other causes of sudden dyspnea should be considered, including heart failure, ischemic heart, pericarditis, pneumonia, pneumothorax, exacerbation of chronic lung disease, and musculoskeletal pain [5][6][7][8]. For patients suspected of pulmonary embolism, tests including ECG, chest film, brain natriuretic peptide and troponin levels, and arterial blood gases are often helpful in differential diagnosis and management [5][6][7][8].…”

“…However, differentiation from other causes of sudden dyspnea should be considered, including heart failure, ischemic heart, pericarditis, pneumonia, pneumothorax, exacerbation of chronic lung disease, and musculoskeletal pain [5][6][7][8]. For patients suspected of pulmonary embolism, tests including ECG, chest film, brain natriuretic peptide and troponin levels, and arterial blood gases are often helpful in differential diagnosis and management [5][6][7][8]. However, a diagnosis of pulmonary embolism should be confirmed by CTA or magnetic resonance pulmonary angiogram.…”

“…Patients who are highly suspected of having this condition and unstable hemodynamics must be fully resuscitated, given anticoagulation and diagnostic imaging. For cases that remain unstable despite resuscitation, bedside echocardiography and compression ultrasonography with Doppler of the leg veins should be used to make a rapid diagnosis to justify the administration of potential life-saving treatment, including thrombolytic agents [5][6][7][8].…”