External Pulmonary Artery Stenosis Mimicking Pulmonary Thromboembolism

Abstract

Acquired pulmonary stenosis is very rare in adults and diagnosis requires a high index ofsuspicion. Malignant mediastinal masses may compress cardiac structures and great vessels.45year-old female patient was admitted to the emergency department with dyspnea and chest pain.Arterial blood gas analysis revealed hypoxia and respiratory alkalosis (pH 7,51, pCO2 65mmHg, pO2 65, HCO3 26 mEq/L, lactate 6 mmol/L).patient had decreased breath sounds inthe right hemithorax, 2-3/6 apical systolic ejection murmur, pretibial edema, jugular venouspressure. Electrocardiogram revealed right axis deviation and sinus tachycardia. D-dimer valuewas 300 ng/ml. Thorax computed tomography angiography revealed no thrombus or dissection.CT revealed soft tissue mass compressing right pulmonary artery and right pleural effusion.External compression of pulmonary artery may clinically mimic pulmonary thromboembolism.Low D-dimer levels may rule out pulmonary thromboembolism. External pulmonary arterycompressions may not increase D-dimer levels.Tomographic imaging should be preferred inpatients with unexplained dyspnea

Keywords

• Mediastinal tumors,pulmonary artery stenosis,D-dimer

PULMONER EMBOLİ KLİNİĞİNİ TAKLİT EDEN EKSTERNAL PULMONER ARTER DARLIĞI

Abstract

Edinilmiş pulmoner stenoz erişkinlerde çok nadir olup tanının konulabilmesi yüksek şüphegerektirir. Mediastinal malign kitleler, kardiyak yapılara ve büyük damarlara bası yapabilir.45yaşında bayan hasta nefes darlığı ve göğüs ağrısı ile acil servise başvurdu. Arteriyel kan gazındahipoksi ve respiratuar alkaloz (pH 7,51, pCO2 26 mmHg, pO2 65, HCO3 26 mEq/L ve laktatdüzeyi 6 mmol/L) tespit edildi. Sağ hemitoraksda solunum seslerinde azalma, kardiyak apeksde2-3/6 sistolik ejeksiyon üfürüm, pretibiyal ödem, juguler venöz dolgunluk,elektrokardiyografisinde sağ aks sapması ve sinüs taşikardisi vardı.D-dimer değeri 300 ng/mlbulundu. Toraks bilgisayarlı tomografi anjiyografisinde trombüs ve diseksiyona rastlanmadı.Toraks tomografisinde sağ efüzyon yanında sağ pulmoner artere bası yapan yumuşak dokukitlesi bulundu. Pulmoner arter external basıları pulmoner tromboemboliyi klinik olarak taklitedebilir. Pulmoner arter embolisini ekarte eden D-dimer seviyesinin düşüklüğü, pulmoner arterexternal basılarında görülebilir. Açıklanamayan dispne olgularında tomografik görüntülemetercih edilmelidir

Keywords

• Mediastinal tümörler,pulmoner arter darlığı,D-dimer

References

1. Kasprzak JD, Religa W, Krzemin˜ska-Pakula M, Marszal- Marciniak, M, Zaslonka J, Pawlowski W. Right ventricular outflow tract obstruction by cardiac metastasis as the first manifestation of follicular thyroid carcinoma. J Am Soc Echocardiogr 1996;9:733-5.
2. Ng AF, Olak J. Pericardial cyst causing right ventricular outflow tract obstruction. Ann Thorac Surg 1997;63:1147-8.
3. Liang CD, Chang JP, Kao CL. Unruptured sinus of valsalva aneurysm with right ventricular outflow tract obstruction associated with ventricular septal defect. Catheter cardiovasc diagn 1996;37:158-61.
4. Chau EM, Cheung KL, Yip AS, Chow WH. Large unrupturedaneurysm in sinus of Valsalva: an unusual cause of rightventricular inflow and outflow tract obstruction. Circulation1998;97:114-5.
5. Sebastian C, Knott CCJ, Chandrasekaran K, Sivaram CA, KugelmassAD,Lazzara pseudoaneurysm causingpulmonary artery obstruction: a rare complication of coronary bypasssurgery: a case report. Angiology 1997;48:1073-8. Giant coronary artery
6. Midiri M, Finazzo M, Gallo C, Hoffman E. Unusual case ofpulmonary artery compression caused by aortic arch aneurysm.Radiol Med (Torino) 1997;93:639-41.
7. Takeda S, Miyoshi S, Omori K, Okumura M, Matsuda H.Surgical rescue for life-threatening hypoxemia caused by a mediastinal tumor. Ann Thorac Surg 1999;68:2324-6.
8. Valls Serral A, Gómez-Aldaraví Gutiérrez R, Chorro Gascó FJ, Muñoz Gil J, Losada Casares JA, Ferrer Casasnovas JV, et al. Extrinsic compression of the pulmonary artery by non- microcytic lung carcinoma. Rev Esp Cardiol 1997;50:208-10.

9. Putterman C, Gilon D, Uretzki G, Bar-Ziv J, Polliack A. Right ventricular outflow tract obstruction due to extrinsic compression by non-Hodgkin’s lymphoma: importance of echocardiographic diagnosis and follow up. Leuk Lymphoma 1992;7:211-5.
10. Mandysová E, Neuzil P, Niederle P, Belohlávek O, Kozák T, Mandys V. Pulmonary stenosis caused by external compression of non-Hodgkin lymphoma.Echocardiography 2004;21:565-7.
11. Soorae AS, Stevenson HM. Cystic thymoma simulating pulmonary stenosis. Br J Dis Chest 1980;74:193-7.
12. Seymour J, Emanuel R, Pattinson N. Acquired pulmo-nary stenosis. Br Heart J 1968;30:776-85.
13. Babcock KB, Judge RD, Bookstein JJ. Acquired pul-monic stenosis. Report of a case caused by mediastinal neoplasm. Circulation 1962;26:931-4.
14. McDonnell PJ, Mann RB, Bulkley BH. Involvement of the heart by malignant lymphoma: a clinicopathologic study. Cancer 1982;49:944-51.
15. Marshall ME, Trump DL. Acquired extrinsic pulmonic stenosis caused by mediastinal tumors. Cancer 1982;49:1496- 9.
16. Özer N, Deveci OS, Kaya EB, Demircin M. Mediastinal lymphoma causing extrinsic pulmonary stenosis. Arch Turk Soc Cardiol, 2009;37:421-424.