Background: Pulmonary embolism (PE) is frequently encountered in emergency departments. It is a serious condition with significant morbidity and mortality. A high prevalence of thromboembolic events has been reported with COVID-19. The similarity in clinical presentation between the two diseases makes accurate diagnosis even more difficult. Atypical presentations can lead to delayed diagnosis and treatment, with a fatal outcome within hours. We report the case of a man presented with bilateral low back pain as a presenting sign of bilateral proximal PE due to COVID-19.
Case Report: A 35-year-old man visited the emergency department for bilateral low back pain with fever. His medical history included type 2 diabetes. Vital signs were as follows: blood pressure was 120/80 mmHg, heart rate was 110 bpm, respiratory rate was 21cpm, desaturation of 80% on room air and temperature was 37.8°C. An unprepared abdominal radiograph revealed significant aerocolia. A thoracoabdomino-pelvic CT scan was performed revealing bilateral proximal pulmonary embolism with floating thrombus of the main pulmonary artery associated with scannographic signs of severity and an extensive COVID-19 pneumonia finding. Anticoagulation was initiated and the patient was transferred to the COVID-19 unit.
Conclusion: The diagnosis of PE should always beconsidered in the presence of any abdominal or lumbar pain of undetermined etiology. The presence of atypical pain in a patient with COVID-19 pneumonia could be a sign of a discrete evolving PE, which should be diagnosed as early as possible to assure timely and appropriate management.
Title
Low back pain revealing bilateral proximal pulmonary embolism with COVID-19
Abstract
Background: Pulmonary embolism (PE) is frequently encountered in emergency
departments. It is a serious condition with significant morbidity and mortality. A high
prevalence of thromboembolic events has been reported with COVID-19. The similarity in
clinical presentation between the two diseases makes accurate diagnosis even more difficult.
Atypical presentations can lead to delayed diagnosis and treatment, with a fatal outcome
within hours. We report the case of a man presented to the emergency department with
bilateral low back pain as a presenting sign of bilateral proximal PE due to COVID-19.
Case Report: A 35-year-old man visited the emergency department for bilateral low back
pain with fever. His medical history included type 2 diabetes. Vital signs were as follows:
blood pressure was 120/80 mmHg, heart rate was 110 bpm, respiratory rate was 21cpm,
desaturation of 80% on room air and temperature was 37.8°C. An unprepared abdominal
radiograph revealed significant aerocolia. A thoracoabdomino-pelvic CT scan was performed
revealing bilateral proximal pulmonary embolism with floating thrombus of the main
pulmonary artery associated with scannographic signs of severity and an extensive COVID-
19 pneumonia finding. Anticoagulation was initiated and the patient was transferred to the
COVID-19 unit.
Conclusion: The diagnosis of PE should always beconsidered in the presence of any
abdominal or lumbar pain of undetermined etiology. The presence of atypical pain in a patient
with COVID-19 pneumonia could be a sign of a discrete evolving PE, which should be
diagnosed as early as possible to assure timely and appropriate management.
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Keywords
Low back pain, pulmonary embolism, COVID-2019
Abbreviations list
PE: Pulmonary embolism, COVID-19: coronavirus disease 2019, LBP: low back pain, ED:
emergency department, aPTT: activated partial thromboplastin time, CT: computed
tomography, RV: right ventricular, LV: left ventricular
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CASE REPORT / SERIES
Introduction
Pulmonary embolism (PE) is frequently encountered in the emergency department. A higher
prevalent of thromboembolic complication has been described recently in patients with
coronavirus disease 2019 (COVID-19), increasing its morbi-mortality [1 ]. Low back pain
(LBP) and abdominal pain are common reasons for emergency department (ED) visits.
Atypical presentation of PE is rare and makes accurate diagnosis even more difficult [2]. The
polymorphism of clinical symptoms of PE and their low sensitivity could be the reason for
delayed diagnosis of this condition, which could be life-threatening within hours. In some
cases, patients with PE may present with unusual symptoms such as LBP and/or
gastrointestinal signs that could refer to other diagnoses related to the affected organ [2].
Further medical evaluation should be considered if no convincing explanation has been found
for the diagnosis of back and abdominal pain, given the potential severity of the underlying
pathology.
Case Presentation
A 35-year-old male patient was admitted to our ED on July 2021 with persistent bilateral
LBP. Initial symptoms have been evolving for 12 days and consisted of Influenza-Like Illness
including fever and asthenia. He attended a General Practitioner who performed a
nasopharyngeal swab followed by detection of the COVID-19 viral genome with reverse
transcriptase-polymerase chain reaction. The test was positive, and the patient was initiated on
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a symptomatic treatment. Regarding the worsening of his medical condition and the onset of
progressive dyspnea associated with intense bilateral LBP spreading to the abdomen, the
patient was referred to our emergency department. No drug, surgical, and smoking history
was reported, but the patient did report a past medical history of type 2 diabetes mellitus.
On examination, the body temperature was 37.8°C. The heart rate was 110 beats per minute
and the blood pressure was 120/80 mmHg. The patient’s respiratory rate was 21 breaths per
minute and the SpO2 was 97% on room air. Heart and pulmonary auscultation were normal.
Glasgow Coma Scale score was 15 and the neurological examination was normal. The
abdomen was tensely distended, painful and tympanic. An electrocardiogram was performed
and revealed a sinus tachycardia over 102 beats per minute. An abdominal X-Ray was done
and found a large bowel gaseous distension (Figure 1).
The blood test results showed Hyperleukocytosis of 17750/mm3 (normal range [4000-
10000/mm3]) with a large amount of neutrophil containing of 14540/mm3 (normal range
[2000-7500/mm3]), hemoglobin of 11.4 g/dl, thrombocytosis of 439000/mm3 (normal range
[150000-400000/mm3]), increased C -reactive protein of 371.7 mg/l (normal range < 5 mg/l),
blood urea of 9.5 mmol/l (normal range 8.3<mmol/l), creatinine of 85 µmol/l (normal range
[62 – 106 µmol/l]), increased high-sensitivity cardiac troponin of 20.9 ng/l (normal range <
14 ng/l), activated partial thromboplastin time (aPTT) ratio of 1.01 and Prothrombin Time of
75% (normal range [70 – 100%]). Other investigations such as liver enzymes, D-Dimer,
arterial blood gas, fibrinogen, procalcitonin and N-Terminal Pro-Brain Natriuretic Peptide
were unavailable.
The evolution was characterized by the rapid drop in oxygen saturation below 80 % on room
air. Chest, abdominal and pelvic computed tomography (CT) scan with contrast revealed a
bilateral proximal PE with a floating clot in the pulmonary trunk associated (Figure 2) with
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heart right dilation (right ventricular (RV) / left ventricular (LV) volume ratio > 1). The
interventricular septum was straight. It also showed bilateral lower lobe predominant ground-
glass opacities associated with crazy paving pattern. The estimated degree of pulmonary
impairment was between 25-50% (Figure 3). Abdominal and pelvic floor was normal.
The patient was transferred to our COVID-19 unit. Thrombolytic therapy was initially
discussed because of critical findings on chest CT-scan. Given the fact that our patient was
hemodynamically stable and did not present signs of heart failure, he was initiated on
unfractionated heparin.
The evolution was characterized by a clinically relevant improvement. Dyspnea and LBP
have completely disappeared. We performed two other chest CT-scans with contrast in the
fourth and the eighth day of hospitalization which revealed a significant improvement in
comparison with the first CT-scan and a regression of the heart right dilation (RV/LV volume
ratio < 1). The patient was discharged home in the fifteenth day of hospitalization, with
instructions to continue the anticoagulant treatment (Rivaroxaban) and re-attend the clinic for
pulmonary and cardiovascular assessment in 1 month.
The informed written consent was obtained from the patient for publication of the report and
radiological findings, as well.
Discussion
The diagnosis of PE is not always easy although there are multiple scores that can be used
such as Well’s criteria and Geneva score, leading us to classify probability in low,
intermediate, and high. These scores guide us to choose the appropriate additional
examinations to establish the diagnosis [3].
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The similarity of respiratory signs in PE and other cardio respiratory diseases could make it
difficult to make an accurate diagnosis as well as clinical signs such as dyspnea, cough,
tachycardia and chest pain are not specific and could be found in other clinical conditions
such as acute coronary syndrome, aortic dissection, pneumothorax, pericarditis [4] and
COVID-19 infection
In front of LBP, physicians usually think of renal or rheumatologic disease first. In this case,
the patient was admitted initially for LBP extending to his abdomen without symptoms
suggestive of PE. He was initially misdiagnosed with a surgical emergency regarding the
large bowel gaseous distension found on the abdominal X-Ray. The appropriate diagnosis
was suspected, and further investigations were performed following the appearance of
desaturation during monitoring.
We looked for similar cases in the PubMed/MEDLINE database using keywords “pulmonary
embolism”, “back pain” and “low back pain”. We found two cases of PE with back pain and
only one case of PE with LBP [1,5,6].
Rare cases of PE revealed by gastrointestinal signs have been reported in about 6.7-11% of
patients with PE which is considered as a significant rate [7].
The mechanisms of LBP in patients with PE are not well known. Some studies suggest that
PE can be responsible for abdominal pain. This one may be caused by gallbladder or liver
capsule dilation induced by right heart failure secondary to PE [7]. Pulmonary hypertension
may cause hepatobiliary portal infiltration and abdominal lymphedema. The elevation of right
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ventricle pressure could be responsible for the re-opening of the foramen ovale which may
decrease blood supply to the abdominal organs [8]. Increased blood viscosity and low oxygen
may induce small embolus that causes focal necrosis of abdominal organs [9]. Some studies
suggest that neurological disorders such as pseudo-ileus can be caused by PE [10]. The last
situation is similar to our case and explains the large bowel gases distension found on the
abdominal X-Ray. Other studies suggest that the abdominal pain may be caused either by
lateral stimulation of the diaphragm or by the stimulation of ending sensitive nerve of the
abdominal wall and the back secondary to thrombus formation in the blood vessel wall [11].
Through this observation, we wanted to highlight the interest of an etiological research of an
unexplained abdominal and LBP with appropriate additional examinations such as chest and
abdominal CT-scan especially in patients with COVID-19 infection so the diagnosis of a
possible PE could be performed earlier.
Conclusion
PE should always be kept in mind in front of atypical symptoms such as LBP and abdominal
pain for which no accurate diagnosis, related to the affected organ, was found. These
symptoms, especially in patients with COVID-19 infection, must draw attention to a possible
PE so that we can establish the diagnosis earlier and treat it if this condition could rapidly
evolve in a negative way.
Conflict of Interest statement
The authors declare no conflict of interest
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