Recurrent Syncope as a Presentation of Pulmonary Embolism

Abstract

Case Report The diagnosis of pulmonary embolism (PE) is challenging especially when patients present with vague symptoms. Early diagnosis and management of PE is crucial to prevent life-threatening sequels. A 60-year-old woman bought by EMS after having syncope while walking. She reported shortness of breath (SOB) before syncope. She has hypertension, type 2 DM, osteoporosis and multiple syncopes (>10) in past year. Her investigation in another hospital includes EKG, 24-hour telemetry, echocardiogram and stress-test were normal but did not have chest CT. Her vital signs and exam were normal. Blood tests and EKG were unremarkable except mild anemia (Hb10.9) and elevation of troponin T (0.015). She was advised to admit but signed out against advice. On way out, she had another syncope that recovered spontaneously but had worsening SOB. She had tachypnea, respiratory distress and hypoxemia, oxygen saturation in 60s. Chest CTA showed prominent bilateral PE. She received heparin and thrombolysis (EKOS). Doppler sonography found occlusive thrombosis left popliteal vein with parti-ally occlusive distal left superficial femoral vein. She was discharged on apixaban. Her SOB improved and no recurrent syncope was reported. PE is a differential diagnosis for syncope in most textbooks, but when patients came due to syncope, PE, a potentially fatal disease requiring urgent attention, is rarely considered. This case is interesting as a patient had multiple syncopes without suspicious of PE until developing severe hypoxemia. PE should be considered in all patients experience syncope particularly with SOB, respiratory distress and hypoxemia.