Content area
Full Text
Background
'Common things are common' but occasionally what seems to be a definite diagnosis may be incorrect. D-dimer is a breakdown of thrombus and may be elevated in conditions other than acute pulmonary embolism. In fact, D-dimer levels are significantly elevated in acute aortic syndromes associated with intramural haematoma. Aortic dissection is not the only acute aortic syndrome and some patients may present with very atypical symptoms. Urgent specialist consultation should be requested in suspicious cases.
Case presentation
A 69-year-old, previously fit and healthy, female presented with a 2 day history of acute right calf pain and sharp left-sided chest pain, associated with progressive worsening shortness of breath. The chest pain was pleuritic in nature, the patient describing it as sharp and worse on inspiration. The chest pain did not radiate. She had a history of flu-like symptoms, with the onset coinciding with a recent 4 h flight from a beach resort. She had no major medical history apart from recently diagnosed mild hypertension. She smoked 15 cigarettes daily and was not on any regular medication. Family history was unremarkable.
On examination, she had a tachycardia of 120/min, blood pressure was 139/81 mm Hg, initial temperature was normal at 37.2 o C but later she developed a low-grade fever. She was tachypnoeic with a respiratory rate of 24/min and pulse oximetry was consistent with mild hypoxia with a saturation of 94% on room air. Clinically, she appeared to be mildly short of breath but was able to complete full sentences. The cardiovascular examination was essentially unremarkable, jugular venous pressure was not raised and there were no murmurs. Pulses were equal and there was no radio-radio delay or blood pressure differential between the two arms. She had mild tenderness of the right calf but no obvious swelling, heat or other signs of venous thrombosis.
Investigations
Inflammatory markers were raised with a C-reactive protein of 168 mg/dl (normal <5 mg/dl). White cell count was 15.9 (normal 4-11 109 /l) with neutrophils of 13 (normal 2-7.5 109 /L). Haemoglobin was 11.7 g/dl (normal 13-18g/dl) and D-dimer of 1849 (normal 0-200 ng/ml).
Arterial blood gas on room air showed a pH of 7.49; pCO2: 4.6 kPa; pO2: 7 kPa; Sat: 93%; base excess: 2.7; HCO3: 26.8; lactate:...