CH3 Intra-pneumonic consolidation pulmonary thromboembolism. (Chest Diseases).

CH3 INTRA-PNEUMONIC CONSOLIDATION PULMONARY THROMBOEMBOLISM. George M. Tadros, MD. Geisinger Medical Center, Danville, Pa.

A healthy 56-year-old white female presented to her primary care physician with symptoms of pneumonia. Her chest x-ray revealed a right upper lobe consolidation and her sputum gram stain was positive for gram positive cocci. The patient was started on oral azithromycin therapy. However, after five days of appropriate therapy the patient presented to the emergency department with symptoms of unremitting shortness of breath, dry cough and right side pleuritic chest pain. A repeat chest x-ray revealed the same upper lobe consolidation. Her WBC count was 5,300 with a relative increase in the bands (12%). The patients arterial blood gas revealed moderate hypoxemia ([PaO.sub.2] 56) on a 100% [O.sub.2] mask. Her d-dimer was elevated at 3.32 [micro]g/mL. With the increased index of suspicion for pulmonary embolism, the patient underwent a ventilation/perfusion scan which revealed an area of matched ventilation and perfusion defects in the right upper lobe while the rest of the lung was normal. The patient then had a CT pulmonary angiogram that revealed a localized area of right pulmonary arterial thrombosis in the area of the pneumonic consolidation with a degree of recanalization and distal embolism. There was no other evidence of thromboembolic disease in the other lung lobes. With these findings the patient was started on intravenous heparin infusion to keep the activated partial thromboplastin time (aPTT) 2-2.5 times normal. She subsequently underwent serial compression duplex studies of the lower and upper extremities that excluded peripheral thromboembolic cliseases. The patient was started on the third clay of hospitalization on warfarin and the heparin was stopped when she reached a therapeutic INR. After discharge, the patient's condition continued to improve in her follow up office visits. Her right upper lobe consolidation resolved within two months. Six months post discharge she was taken off the warfarin and after a period of six weeks she underwent blood studies to test for thrombophilic blood disorders tha t were all negative. Intra-pneumonic consolidation pulmonary thromboembolism has been reported in the veterinary literature. However, its incidence in human beings has been reported only once in the past. It is postulated that the severe local infection and inflammation activates the local coagulation cascade culminating in thrombosis and downstream embolism. Suspicion for pulmonary thromboembolic diseases is indicated in patients with refractory pneumonia on adequate therapy.