Golse Marianne, Barat Maxime, Costedoat-Chalumeau Nathalie, Revel Marie-Pierre
From the Departments of Radiology (M.G., M.B., M.P.R.) and Internal Medicine (N.C.C.), Cochin Hospital, APHP Centre, 27 Rue du Fg St Jacques, Paris 75014, France; and Université de Paris, Paris, France (M.B., N.C.C., M.P.R.).
Radiology. 2021 Jun;299(3):727-729. doi: 10.1148/radiol.2021203170.
History A 50-year-old woman presented to the emergency department of our hospital with a 2-day history of lower limb pain associated with unusual asthenia and diffuse arthralgia over the past 3 weeks. She was a native of Guinea and had lived in France for most of her life, working as a personal care assistant. Her only medical history of note was an occurrence of fetal death at 12 weeks gestation when she was 35 years old. She had bilateral lower limb swelling, without changes in skin temperature or color. All proximal and distal arterial pulses were felt. General physical examination findings were otherwise unremarkable. Her laboratory tests showed a decreased hemoglobin concentration of 8.9 g/dL (normal range, 12-16 g/dL), a decreased platelet count of 45 × 10/L (normal range, 150-400 × 10/L), a C-reactive protein level of 158 mg/L (normal range, <5 mg/L) and a d-dimer level of 2000 mg/L (normal range, <500 mg/L). Compression US of the lower limbs revealed bilateral calf vein thrombosis involving the fibular and posterior tibial veins. Curative anticoagulation using low-molecular-weight heparin (enoxaparin, subcutaneous injection of 100 units per kilogram of body weight twice a day) was started. The day after the start of anticoagulation therapy, the patient reported dyspnea and acute chest and abdominal pain. Her vital signs were assessed, and she had elevated blood pressure and increased heart rate and respiratory rate, but she remained afebrile. Her cardiac auscultation was unremarkable, besides tachycardia. Skin examination revealed small areas of necrosis on the fingertips of her right hand. Laboratory studies were repeated and showed an increase in serum creatinine level from a baseline value of 0.49 mg/dL to a new value of 1.01 mg/dL (normal range, 0.6-1.1 mg/dL), an apparition of low-grade proteinuria of 0.43 g per day (normal range, <0.3 g/day), and a high serum troponin level of 1066 ng/L (normal range, <14 ng/L), whereas electrocardiography showed no ST segment modification and echocardiography revealed a moderately altered left ventricular ejection fraction (45%). There was no coronary occlusion seen at emergency coronarography. Contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Figs 1, 2) together with cardiac MRI (Figs 3, 4).
一名50岁女性因下肢疼痛2天前来我院急诊科就诊，在过去3周还伴有异常乏力和弥漫性关节痛。她来自几内亚，一生大部分时间生活在法国，职业是私人护理助理。她唯一值得注意的病史是35岁时怀孕12周发生胎儿死亡。她双侧下肢肿胀，皮肤温度和颜色无变化。双侧近端和远端动脉搏动均能触及。其他常规体格检查结果无异常。实验室检查显示血红蛋白浓度降至8.9 g/dL（正常范围12 - 16 g/dL），血小板计数降至45×10⁹/L（正常范围150 - 400×10⁹/L），C反应蛋白水平为158 mg/L（正常范围＜5 mg/L），D - 二聚体水平为2000 mg/L（正常范围＜500 mg/L）。下肢加压超声显示双侧小腿静脉血栓形成，累及腓静脉和胫后静脉。开始使用低分子量肝素（依诺肝素，皮下注射，每千克体重100单位，每日两次）进行治疗性抗凝。抗凝治疗开始后的第二天，患者报告出现呼吸困难以及急性胸痛和腹痛。对其生命体征进行评估，发现她血压升高、心率和呼吸频率增加，但仍无发热。除心动过速外，心脏听诊无异常。皮肤检查发现右手指尖有小面积坏死。重复进行实验室检查，结果显示血清肌酐水平从基线值0.49 mg/dL升至新值1.01 mg/dL（正常范围0.6 - 1.1 mg/dL），出现每日0.43 g的轻度蛋白尿（正常范围＜0.3 g/天），血清肌钙蛋白水平升高至1066 ng/L（正常范围＜14 ng/L），而心电图显示无ST段改变，超声心动图显示左心室射血分数中度降低（45%）。急诊冠状动脉造影未见冠状动脉闭塞。进行了胸部、腹部和骨盆的增强CT扫描（图1、2）以及心脏MRI检查（图3、4）。
