Pulmonary Infarction Clinical Presentation

Updated: Jan 15, 2020
  • Author: Lennox H Huang, MD, FAAP; Chief Editor: Michael R Bye, MD  more...
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Presentation

History

Classic symptoms of pulmonary embolism (PE) are rarely encountered. The frequency with which the diagnosis is missed in both adults and children is striking. Adding to the clinical dilemmas is the fact that few symptoms are sensitive or specific for pulmonary embolism. In adult series, clinical diagnosis has a sensitivity of 85% but a specificity of 38%, reflecting the vast differential diagnosis found in both adults and children. Symptoms vary according to the severity of the pulmonary embolism and the presence of underlying conditions. Pulmonary emboli of small-to-moderate size are generally asymptomatic.

Respiratory symptoms

Pleuritic chest pain is reported to occur in as many as 84% of children and adults with pulmonary emboli. Its presence suggests that the embolus is located more peripherally and, thus, may be smaller.

Tachypnea and dyspnea are observed in as many as 60% of adult patients with pulmonary emboli but are generally less frequent in children.

Cough is present in approximately 50% of children with pulmonary emboli. Hemoptysis is a feature in a minority of children with pulmonary emboli, occurring in about 30% of cases.

Other symptoms

A feeling of apprehension is a manifestation of arousal of the sympathetic system. Sweating and syncope are rarely present.

Risk factors to elicit on history taking

Obtain a detailed history of any previous pulmonary embolism/thromboembolism, oral contraceptive use, recent pregnancy, termination of pregnancy, drug history, and family history.

Sickle cell disease

Patients with sickle cell disease may present with manifestations of sickle cell anemia other than acute chest syndrome. These may include anemia, sequestration crisis, pain crisis, stroke, and priapism.

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Physical Examination

The use of physical findings as a diagnostic aid in suspected cases of pulmonary embolism brings the same problems as are outlined in History. Many physical findings are typically less marked than they are in adults, presumably because children have greater hemodynamic reserve and, thus, are better able to tolerate the significant hemodynamic and pulmonary changes.

Pulmonary findings include the following:

  • Tachypnea is a feature in almost 50% of children with pulmonary emboli.

  • Crackles are heard in a minority of cases.

  • Cyanosis and hypoxemia are not prominent features of pulmonary embolism. If present, cyanosis suggests a massive embolism leading to a marked V/Q mismatch and systemic hypoxemia. Some case reports have described massive pediatric pulmonary embolism with normal saturation.

  • A pleural rub is often associated with pleuritic chest pain and indicates an embolism in a peripheral location in the pulmonary vasculature.

  • Signs that indicate pulmonary hypertension and right ventricular failure include a loud pulmonary component of the second heart sound, right ventricular lift, distended neck veins, and hypotension. An increase in pulmonary artery pressure is reportedly not evident until at least 60% of the vascular bed has been occluded.

Cardiovascular findings include the following:

  • A gallop rhythm signifies ventricular failure.

  • Peripheral edema is a sign of congestive heart failure.

  • Various heart murmurs may be audible, including a tricuspid regurgitant murmur signifying pulmonary hypertension.

Other signs include the following:

  • Fever is an unusual sign that is nonspecific.

  • Diaphoresis is a manifestation of sympathetic arousal.

  • Signs of other organ involvement in patients with sickle cell disease would be elicited, such as sequestration crisis, priapism, anemia, and stroke.

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Complications

Complications of pulmonary embolism include the following:

  • Death

  • Hemorrhage

  • Heparin-induced thrombocytopenia

  • Thrombophlebitis

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