A 27-year-old woman presented for a second opinion with chest pain, dyspnea, and a worsening rash with new pustules. Three weeks before presentation she developed a small rash on her anterior right lower abdomen. After treatment with topical hydrocortisone and mupirocin, oral valganciclovir and clindamycin, the rash increased in size, developed central clearance, and became warm and edematous. After development of lymphadenopathy in her right axilla and inguinal regions, she was admitted to an outside hospital and treated with intravenous vancomycin, piperacillin and tazobactam, and topical ketoconazole and was discharged home on doxycycline. After discharge she developed lower extremity edema, pleuritic chest pain, dyspnea, and a 10-lb weight gain. Two days before presentation she presented to an outside emergency department, had computed tomography (CT) angiography of her chest that did not reveal a pulmonary embolus, and was sent home with oral furosemide. She had a history of nephrolithiasis, and was currently taking furosemide and an oral contraceptive (drospirenone and ethinyl estradiol). She worked as a nurse and had no recent travel or sick contacts.
Assessment
On admission the patient had a temperature of 36.9°C, blood pressure 117/78 mm Hg, a heart rate of 97 beats per minute, respiratory rate of 16, an oxygen saturation of 98% on room air, and a weight of 75.2 kg. She appeared in no acute distress. Her heart was tachycardic without murmur, and her lungs were clear to auscultation. On the right lower abdomen she had an 8 × 6-cm oval erythematous patch with approximately 10 to 20 2- to 3-mm erythematous pustules (Figures 1 and 2). She had bilateral symmetric edema with no calf tenderness. Laboratory analysis was significant for leukocytosis (18.3 103 cells/mL with 74% neutrophils). Results from a chest radiograph, brain natriuretic peptide measurement, and electrocardiogram were normal. The following day her heart rate increased to 150 s (sinus tachycardia) with ambulation, and her pleuritic chest pain persisted. Because our clinical suspicion remained high for pulmonary embolism, a repeat CT angiogram of the thorax was ordered, and dermatology was consulted for her rash.
Diagnosis
Typically in our practice we do not repeat angiograms to evaluate for pulmonary embolism, because numerous cohort studies have reported a low incidence (<2%) of pulmonary embolism in patients with a low clinical suspicion of pulmonary embolism and a negative CT angiogram in whom technically advanced scanners and specific pulmonary embolism protocols were used.1, 2 Our patient was recently hospitalized at an outside institution and did not receive deep vein thrombosis prophylaxis, was on an oral contraceptive, and had a presentation suspicious for pulmonary embolism. In addition, a prospective multicenter outcome study in France determined that when a patient has a high suspicion for pulmonary embolism and a negative CT angiogram, the risk of missing a pulmonary embolism is higher (5%).3 Our clinical suspicion and literature review proved valuable: her repeat CT angiogram of the thorax revealed multiple bilateral subsegmental pulmonary emboli involving all lobes.
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-Jeffrey J. Wargo, MD, Aaron Berg, MD, Johann E. Gudjonsson, MD, PhD
This article originally appeared in the September 2016 issue of The American Journal of Medicine.
