Working Diagnosis:
Pulmonary Embolus secondary to exercise induced deep vein thrombosis (DVT)

Treatment:
Patient was placed on 6 months of warfarin therapy bridged with heparin.

Outcome:
The patient finished his warfarin treatment plan and has had no additional adverse effects. His activity has returned to baseline and has presented with no further medical condition.
His coagulation work up was negative for abnormalities following the conclusion of his anticoagulation therapy.

Author's Comments:
Pulmonary Embolism is a life threatening condition which1 is usually characterized by pleuritic chest pain, dyspnea, as well as cyanosis in severe cases. Fifteen percent of all cases of sudden death are attributable to PE. The infrequency with which it is encountered in adolescents, combined with its frequently silent presentation, makes it a potentially overlooked diagnosis. This case demonstrates the importance of awareness and education in acute, life threatening conditions and the significance of a complete history. Without the somatic complaints of the opposite ribs, the patient may have never presented to the emergency room. Weight training is a common cause of musculoskeletal pain in this age group. Despite some signs of pulmonary embolism's presence, many factors such as the age of patient, the quality of the pain, and limited initial history pointed to more benign causes. However, even in this relatively low risk age group, pulmonary embolism along with coronary artery anomalies and hypertrophic cardiomyopathy should always be considered. More education about exercise induced life threatening conditions such as hypertrophic cardiomyopathy, coronary artery anomalies, and pulmonary embolisms should be provided in well care visits.

In clinical presentations such as our adolescent weight-lifter with chest pain, the provider should consider a D-Dimer. This test can be especially helpful when the clinical suspicion for a pulmonary embolism is low. The test carries a high sensitivity (95%), but low specificity (50%) of the d-dimer test. However, without the D-Dimer, his diagnosis or pulmonary embolism and deep venous thrombosis could have easily been missed, and potentially let to a catastrophic event in the future.

Even if the diagnosis seems apparent, if criteria is met such as Well's Criteria a D-Dimer should be ordered as the numerous studies that show a properly ordered D-Dimer reduces mortality includes incidental PE findings such as this case.
Case Photo #3 Case Photo #4

Editor's Comments:
While PE is less common in young healthy patients it is important to keep on the differential with acute onset chest pain and shortness of breath.
In this setting a positive D-dimer is an excellent test to help guide further testing.

References:
1. Righini M, Van Es J, Den Exter PL, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 311:1117-1124.
2. Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ 2006; 175:1087.
3. Wells PS, Brill-Edwards P, Stevens P, et al. A novel and rapid whole-blood assay for D-dimer in patients with clinically suspected deep vein thrombosis. Circulation 1995; 91:2184.
4. Konstantinides S,Torbicki A,2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism.European Heart Journal Aug 2014, DOI: 10.1093/eurheartj/ehu283

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