A 60-year-old woman with a 6-week history of shortness of breath and intermittent chest pain due to chronic thromboembolic pulmonary disease undetected by computed tomography pulmonary angiography (CTPA) and diagnosed by ventilation-perfusion imaging

Yanagisawa, Y; Hassan Ibrahim, W; kumar, N; Cooper, J

A 60-year-old woman with a 6-week history of shortness of breath and intermittent chest pain due to chronic thromboembolic pulmonary disease undetected by computed tomography pulmonary angiography (CTPA) and diagnosed by ventilation-perfusion imaging

Authors

Yanagisawa, Y

Hassan Ibrahim, W

kumar, N

Cooper, J

Issue Date

2022

Type

Scientific Paper

Keywords

Research Subject Categories::MEDICINE::Dermatology and venerology,clinical genetics, internal medicine::Internal medicine::Lung diseases

Abstract

BACKGROUND Chronic thromboembolic pulmonary disease (CTEPD) is the persistent occlusion of pulmonary arteries resulting from 1 or more thrombo-emboli. Its presentation is often non-specific, with exertional dyspnea and fatigue, yet if left undiagnosed risks of chronic thromboembolic pulmonary hypertension and right-sided cardiac failure can ensue. Computed tomography pulmonary angiography (CTPA) and ventilation/perfusion (V/Q) imaging are most commonly utilized for investigating CTEPD. This report is of a 60-year-old woman with a 6-week history of breathlessness and intermittent chest pain due to CTEPD, undetected by CTPA and diagnosed by V/Q imaging. CASE REPORT A 60-year-old woman presented with a 6-week history of breathlessness, intermittent chest pain, and reduced mobility. Her past medical history included chronic obstructive pulmonary disease, pulmonary sarcoidosis, and obesity. Screening tests for infective and ischemic cardiac etiologies were unremarkable. A calculated Wells score was 6, making CTEPD the main differential diagnosis, and she was commenced on therapeutic dose anticoagulation. A CTPA performed on day 2 of admission showed no evidence of acute thromboembolic pulmonary disease or CTEPD. Instead, V/Q scintigraphy on day 6 revealed a perfusion mismatch in the right lung apex, consistent with CTEPD. The patient improved clinically and was discharged on long-term apixaban. CONCLUSIONS A negative CTPA does not necessarily exclude CTEPD. The sensitivity of CTPA for CTEPD is lower than that of V/Q imaging, and can hence lead to false-negative results, as this case highlights. When there is a high clinical suspicion for CTEPD but a negative CTPA study, V/Q imaging should always be undertaken. PubMed Disclaimer Conflict of interest statement Conflict of interest: None declared Figures Figure 1. Figure 1. Erect anterior-posterior chest radiograph performed… Figure 2. Figure 2. Axial slices of the computed… Figure 3. Figure 3. Ventilation/Perfusion (V/Q) scan in the… Similar articles Ventilation/Perfusion SPECT lung scintigraphy and computed tomography pulmonary angiography in patients with clinical suspicion of pulmonary embolism. Ibáñez-Bravo S, Banzo I, Quirce R, Martínez-Rodríguez I, Jiménez-Bonilla J, Martínez-Amador N, Parra JA, González-Macías J, Carril JM. Rev Esp Med Nucl Imagen Mol. 2016 Jul-Aug;35(4):215-20. doi: 10.1016/j.remn.2015.12.008. Epub 2016 Jan 30. PMID: 26838481 English, Spanish. Planar and SPECT ventilation/perfusion imaging and computed tomography for the diagnosis of pulmonary embolism: A systematic review and meta-analysis of the literature, and cost and dose comparison. Phillips JJ, Straiton J, Staff RT. Eur J Radiol. 2015 Jul;84(7):1392-400. doi: 10.1016/j.ejrad.2015.03.013. Epub 2015 Mar 20. PMID: 25868674 Review. Planar ventilation-perfusion imaging for pulmonary embolism: the case for "outcomes" medicine. Freeman LM, Glaser JE, Haramati LB. Semin Nucl Med. 2012 Jan;42(1):3-10. doi: 10.1053/j.semnuclmed.2011.07.003. PMID: 22117808 Review. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. Anderson DR, Kahn SR, Rodger MA, Kovacs MJ, Morris T, Hirsch A, Lang E, Stiell I, Kovacs G, Dreyer J, Dennie C, Cartier Y, Barnes D, Burton E, Pleasance S, Skedgel C, O'Rouke K, Wells PS. JAMA. 2007 Dec 19;298(23):2743-53. doi: 10.1001/jama.298.23.2743. PMID: 18165667 Clinical Trial. Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thromboembolic pulmonary disease as a treatable cause of pulmonary hypertension. Tunariu N, Gibbs SJ, Win Z, Gin-Sing W, Graham A, Gishen P, Al-Nahhas A. J Nucl Med. 2007 May;48(5):680-4. doi: 10.2967/jnumed.106.039438. PMID: 17475953 See all similar articles References McCabe C, Dimopoulos K, Pitcher A, et al. Chronic thromboembolic disease following pulmonary embolism: time for a fresh look at old clot. Eur Respir J. 2020;55(4):190–94. - PubMed Pahal P, Sharma S. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing; 2022. Jan, Secondary pulmonary hypertension. 2021 Aug 11. Available at: https://www.ncbi.nlm.nih.gov/books/NBK526008/ - PubMed Kovacs G, Zeder K, Rosenstock P, et al. Clinical impact of the new definition of precapillary pulmonary hypertension. Chest J. 2021;159(5):1995–97. - PubMed Held M, Grun M, Holl R, et al. Chronic thromboembolic pulmonary hyper-tension: Time delay from onset of symptoms to diagnosis and clinical condition at diagnosis. Dtsch Med Wochenschr. 2014;139(33):1647–52. - PubMed Miller A. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thor. 2003;58(6):474–83. - PMC - PubMed Show all 18 references Publication types Case Reports MeSH terms Angiography / methods Chest Pain / etiology Dyspnea / etiology Female Humans Lung Middle Aged Perfusion Perfusion Imaging Pulmonary Embolism* / diagnostic imaging Radionuclide Imaging Thromboembolism* Tomography, X-Ray Computed Ventilation-Perfusion Ratio Related information MedGen LinkOut - more resources Full Text Sources Europe PubMed Central International Scientific Literature, Ltd. PubMed Central Medical Genetic Alliance MedlinePlus Health Information Miscellaneous NCI CPTAC Assay Portal

Citation

Yanagisawa Y, Hassan Ibrahim W, Kumar N, Cooper J. A 60-Year-Old Woman with a 6-Week History of Shortness of Breath and Intermittent Chest Pain Due to Chronic Thromboembolic Pulmonary Disease Undetected by Computed Tomography Pulmonary Angiography (CTPA) and Diagnosed by Ventilation-Perfusion Imaging. Am J Case Rep. 2022 Nov 17;23:e938041. doi: 10.12659/AJCR.938041. PMID: 36395074; PMCID: PMC9679983.