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A 26 year old woman was admitted with fever and illness caused by an infiltration of the lingula. The day after admittance, symptoms of acute dyspnoea and tachypnoea developed. Pulmonary embolism was suspected. A perfusion scan showed complete absence of perfusion of the right lung with abnormalities in the left lung fitting her extensive lingula infiltration (below left: panel A). Pulmonary angiography was carried out to determine the precise location of the obstruction. This showed a total obstruction directly proximal in the right pulmonary artery (below centre: A, superior vena cava; B, truncus pulmonalis; C, obstruction). The patient received frontloading recombinant tissue plasminogen activator (r-tPA). Then transoesophageal echocardiography was performed. A massive thrombus was visible with almost complete obstruction of the vessel (below right: A, aorta; B, thrombus).
The next day the patient underwent a controlled ventilation–perfusion scan which still showed a major perfusion defect of the right lung (below left: panel B) during normal ventilation (panel C). Because of threatening respiratory insufficiency, she underwent an embolectomy. The procedure was completed without complications. Echographic examination of the pelvis and legs showed total thrombosis of the right femoral vein and a thrombus in the wall of the left iliac communis vein. Therefore a vena cava filter was introduced postoperatively. Three weeks after surgery she was discharged from hospital in good health.
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