Case report: Acute massive pulmonary embolism treated by alteplase.
Authors: Khawar Shoaib Khawar Shoaib 
Published: August 2024

Background: Pulmonary embolism is a common and some time fatal disease that continues to persist despite advance in diagnosis and management. Pulmonary embolism (PE) is caused by emboli, which have originated from venous thrombi, travelling to and occluding the arteries of the lung. PE is the most dangerous form of venous thromboembolism, and undiagnosed or untreated PE can be fatal. Acute PE is associated with right ventricular dysfunction, which can lead to arrhythmia, haemodynamic collapse and shock. Furthermore, individuals who survive PE can develop post-PE syndrome, which is characterized by chronic thrombotic remains in the pulmonary arteries, persistent right ventricular dysfunction, decreased quality of life and/or chronic functional limitations. Several important improvements. In patients younger than 55 years, the incidence of pulmonary is higher in females. Once deep venous thrombosis develops, clots may dislodge and travel through the venous system and the right side of the heart to lodge in the pulmonary arteries, where they partially or completely occlude one or more vessels.
CASE PRESENTATION
       A 65 year old hypertensive male resident of Lahore was in usual state of health when he develop shortness of breath which was sudden in onset and gradually worsen. It was not associated with chest pain, swelling of legs, edema. Previously he was only hypertensive. He has no family history of such illness. On presentation his vitals show hypotension, tachycardia and tachypnea with drop in saturation. Investigations of the patient carried out, blood investigation showed increase TlC,
 D-dimer raised, trop positive, PT, aptt normal, Hb, PLT count were also normal. ECG OF THE Patient showed sinus tachycardia with large S wave in lead 1, Q wave in lead 3 and inverted T wave in lead 3. Echocardiography of this patient showed dilated RV with intact LV systolic function. X-RAY of the patient shows Hampton hump sign (wedge shape peripheral air disease). CT pulmonary angiogram done which shows bilateral extensive pulmonary embolism involving almost entire left main pulmonary artery with extension into distal right pulmonary artery. there was poor opacification of bilateral lower limb deep veins for which Doppler bilateral lower limb planned. On above these finding patient was treated at line of pulmonary embolism. Patient symptom improved and was discharged on oral anticoagulant with follow up care advise.
ECG showed sinus tachycardia. Large S wave in lead 1, Q wave in lead III and invented T wave in lead III.
There was Bilateral Pleural Effusion and Right side consolidation.
DISCUSSION
We report an interesting case of PE. Although cases of DVT have been associated with this syndrome in the past, only a few cases have presented with acute bilateral pulmonary emboli. This vascular variant should be considered with high suspicion in left lower extremity DVT in young patients with no other etiology to justify thrombosis. Prolonged anticoagulation, thrombectomy or stent placement for the relief of mechanical obstruction have been used in various clinical settings.
A multidisciplinary team input from specialists is the key to provide primary care fundamentally in poorly defined management strategies. Identification of the triggers of thromboembolism is crucial to prevent disease progression and recurrence. In pulmonary embolism with or without infarction in haemodynamically stable patients, anticoagulation should be considered as first-line therapy to yield optimum outcomes.
CONCLUSION:
PE is the result of a clot in the pulmonary artery or one of its branches. If untreated, PE can result in death. Goals of initial treatment include clot resolution; long-term and extended treatment aim to decrease the risk of recurrence. All patients of pulmonary embolism taking anticoagulant medication should have proper follow-up and routine investigations done every 1 to 3 months.