A 44-Year-Old Woman With Chest Pain and Dyspnea

A 44-year-old woman with a medical history of anti-phospholipid antibody syndrome complicated by recurrent pulmonary emboli with subsequent chronic hypoxic respiratory failure (3 L/min oxygen baseline) presented to the ED with 2 to 3 weeks of shortness of breath and pleuritic chest pain that radiated to the center of her back. These symptoms were accompanied by an increase in her oxygen requirement from 3 L/min to 6 L/min. She also reported nausea, vomiting, lightheadedness, and dizziness for the same period. The patient had two prior pulmonary emboli in the same year, which prompted a hypercoagulable workup, ultimately revealing a diagnosis of antiphospholipid antibody syndrome. The second pulmonary embolus occurred while the patient was on coumadin, though achieving a therapeutic international normalized ratio was challenging. At the recommendation of the Hematology Department, she was transitioned to systemic anticoagulation with low-molecular-weight heparin (LMWH) at a dose of 1.5 mg/kg twice daily, which was her regimen at the time of admission. The patient confirmed total compliance with her anticoagulation therapy, and she denied any recent travel or long periods of being sedentary. She was up to date on her age-appropriate cancer screening, without any evidence of active malignancy.