An 80 year-old man presented with one day of confusion, worsened cough, and subjective fevers. He had a productive cough since emigrating from Mexico six months ago, but no complaints of dyspnea. He had a history of diabetes and stable angina for the past year.
On presentation, he was tachycardic with a temperature of 38.4C. He had bilateral crackles up to mid lung fields without any noted oxygen desaturation. He was oriented to self only and was placed on airborne isolation after one episode of bloody sputum in the emergency room. His lactate was elevated, and complete blood count was within normal limits. He had diffuse interstitial markings but no cavitations or effusions on chest x-ray. He was started on ceftriaxone and azithromycin and admitted for community-acquired pneumonia. Sputum acid-fast bacilli (AFB) cultures were sent given his hemoptysis, fever, and recent emigration from Mexico.
Twenty four hours after admission, his symptoms improved, but he remained tachycardic. His blood and urine cultures were negative along with AFB smears. An electrocardiogram was obtained and showed a right bundle branch block. Troponins and beta natriuretic peptide (BNP) were elevated. A CT angiogram of the chest revealed a filling defect concerning for pulmonary embolism. The patient was started on anticoagulation for treatment and clinically improved.
Discussion:
Pulmonary embolism (PE) is commonly seen in the hospital setting. Patients classically present with dyspnea and pleuritic chest pain, but other symptoms include cough, hemoptysis, and leg swelling. The diagnosis of PE can be challenging as its clinical presentation can be variable, and it can often be mistaken for other processes. This patient’s tachycardia, fever, cough, and hemoptysis were attributed to sepsis from pneumonia or tuberculosis. He denied dyspnea and had no oxygen desaturation. He had a WELLS score of 2.5 (hemoptysis and tachycardia), which put him at low to moderate risk for PE. A D-Dimer assay was considered for further risk stratification but dismissed due to concern for a false positive elevation from an infection. His presentation and chief complaint appeared to be more consistent with an infectious process, which led to anchoring bias and premature closure on the diagnosis of pneumonia or tuberculosis. Both pneumonia and PE can have overlapping features that can pose a diagnostic dilemma. Even though fever is more common with pneumonia, it can be present in nearly 50% of cases of PE. The intermittent tachycardia, right bundle branch block, and elevated troponin and BNP pushed us to further evaluate for pulmonary embolism.
Conclusions:
Early diagnosis of PE can be a challenge when classic symptoms are masked by confounding factors like sepsis. This case highlights how PE can mimic infection, and the importance of being aware of anchoring bias and premature diagnostic closure in patients whose presentation could be consistent with pulmonary embolism.