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Submassive acute pulmonary thromboembolism with normal D-dimer. A case report
A Di Grande1, V Tomaselli, L Massarelli
1Unit of Emergency Medicine and Surgery, S. Elia Hospital, Caltanisetta, Italy. adigrande@yahoo.it
Minerva Cardioangiologica
|June 17, 2006
Summary
A normal plasma D-dimer test did not rule out pulmonary thromboembolism in a patient with dyspnea. This case highlights diagnostic challenges for pulmonary thromboembolism, even with normal D-dimer levels.
Area of Science:
- Cardiology
- Pulmonology
- Emergency Medicine
Background:
- Pulmonary thromboembolism (PTE) is a common emergency department diagnosis.
- Diagnosis relies on risk factors, clinical evaluation, and investigations.
- Plasma D-dimer is a sensitive but not specific biomarker for PTE screening.
Observation:
- A 74-year-old woman presented with sudden dyspnea.
- Initial plasma D-dimer levels were normal (253 ng/mL).
- Spiral CT angiography revealed sub-massive PTE involving the right pulmonary artery and lobar branches.
Findings:
- Cardiac echo-color-Doppler showed right heart enlargement and elevated pulmonary artery pressure (74 mmHg).
- A second D-dimer measurement 12 hours later remained normal (274 ng/mL).
- D-dimer levels significantly increased to 1017 ng/mL only after four days.
Implications:
- This case underscores the diagnostic difficulties of PTE, particularly when D-dimer results are discordant with clinical suspicion.
- It highlights the limitations of relying solely on D-dimer for ruling out PTE, especially in specific patient presentations.
- The findings suggest a need for careful clinical judgment and consideration of advanced imaging despite normal initial biomarker results.