CHEST Guidelines-A-77-Year-Old-Woman-With-Acute-Shortness-of-Breath

A-77-Year-Old-Woman-With-Acute-Shortness-of-Breath

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A 77-year-old woman presented with acute shortness of breath and right-sided pleuritic chest pain. Her medical history included a carcinoid tumor resected in 2012, and she was on medications like amlodipine and rosuvastatin. Upon examination, she demonstrated tachypnea with normal oxygen saturation. Diagnostic tests revealed elevated N-terminal pro–brain natriuretic peptide levels, normal troponin levels, and sinus tachycardia on ECG. A transthoracic echocardiogram indicated a hypokinetic right ventricular wall with preserved right apex contractility, known as McConnell’s sign, which is often associated with pulmonary embolism but was suggestive of a pressure overload in the right ventricle in this case. A venous Doppler ultrasound was negative, but a CT scan of the chest eventually diagnosed pulmonary vein thrombosis (PVT).<br /><br />PVT often goes undiagnosed despite having symptoms like dyspnea and chest pain. It is rare without evident risks like coagulopathy or recent surgeries, making this an idiopathic case. The patient's extensive evaluation for hypercoagulopathy, autoimmune disorders, and malignancy revealed no underlying cause. McConnell’s sign, identified here, is traditionally linked to pulmonary embolism but can occur in PVT cases due to right ventricular pressure overload.<br /><br />Treatment included anticoagulation with heparin transitioning to rivaroxaban for three months, leading to complete resolution of the thrombus. This case underscores the importance of considering PVT in differential diagnoses for associated symptoms despite its rarity, especially in idiopathic contexts. Management typically involves anticoagulation, with surgical options reserved for unstable patients.

Keywords

pulmonary vein thrombosis

idiopathic case

McConnell’s sign

anticoagulation treatment

right ventricular pressure overload

tachypnea

dyspnea

chest pain

rivaroxaban

heparin