Hoskote Abhinav, Sudadi Shreya, Dembo Brent, Consolini Michelle, Kashyap Rahul
Department of Internal Medicine, WellSpan York Hospital, York, USA.
Department of Cardiology, WellSpan York Hospital, York, USA.
Eur J Case Rep Intern Med. 2024 Nov 25;11(12):005031. doi: 10.12890/2024_005031. eCollection 2024.
Venous thromboembolism (VTE) rarely presents with dizziness as the primary complaint, which can delay diagnosis. We report a rare case of dizziness as the chief complaint for a clot-in-transit and extensive bilateral pulmonary emboli.
A 70-year-old woman presented to the emergency room (ER) with dizziness and a fall, without reporting loss of consciousness. Her symptoms included positional dizziness, tinnitus and visual darkness, alongside prior exertional fatigue and dull chest pressure. Despite a history of left leg oedema and inconsistent use of medications for hypertension and diabetes, initial examinations suggested vestibular neuritis and decompensated heart failure, confirmed by echocardiogram findings and response to prednisone. While hospitalised, she experienced pre-syncope after showering, initially deemed vasovagal. However, exertional hypotension led to further investigation, revealing right heart strain. Ultrasound identified a left popliteal deep vein thrombosis, and a computed tomography (CT) angiogram confirmed extensive bilateral pulmonary emboli with right heart strain. Cardiology discovered large, mobile thrombi in transit in the heart, necessitating an urgent mechanical thrombectomy. Following treatment, her pulmonary pressure improved, and she was discharged on anticoagulation medicine. One month later, an echocardiogram showed normalised heart function.
This case highlights the importance of differentiating dizziness from pre-syncope, as exertional pre-syncope can indicate an obstructive physiology such as VTE. Cognitive bias can obscure diagnosis in atypical presentations. A pulmonary embolism response team could improve management of these cases, where prompt diagnosis and treatment are essential for favourable outcomes.
Cognitive bias should be consistently challenged while ruling out pulmonary emboli based on the absence of typical signs.It is essential to differentiate vertigo from light-headedness or pre-syncope in patients presenting with a complaint of dizziness.Pre-syncope can be an important presenting complaint of haemodynamically significant pulmonary emboli and clots in transit.
静脉血栓栓塞症（VTE）很少以头晕作为主要症状就诊，这可能会延误诊断。我们报告一例罕见病例，该患者以头晕为主要症状，诊断为移行性血栓和广泛双侧肺栓塞。
一名70岁女性因头晕和跌倒就诊于急诊室（ER），未报告意识丧失。她的症状包括体位性头晕、耳鸣和视物模糊，同时伴有既往劳力性疲劳和胸部闷痛。尽管有左腿水肿病史，且高血压和糖尿病用药不规律，但初步检查提示前庭神经炎和失代偿性心力衰竭，超声心动图检查结果及对泼尼松的反应证实了这一诊断。住院期间，她淋浴后出现晕厥前症状，最初认为是血管迷走性晕厥。然而，劳力性低血压促使进一步检查，发现右心劳损。超声检查发现左侧腘静脉深静脉血栓形成，计算机断层扫描（CT）血管造影证实广泛双侧肺栓塞伴右心劳损。心脏病学检查发现心脏内有大量移动性血栓，需要紧急进行机械取栓术。治疗后，她的肺动脉压力有所改善，出院时服用抗凝药物。一个月后，超声心动图显示心功能恢复正常。
该病例强调了区分头晕与晕厥前症状的重要性，因为劳力性晕厥前症状可能提示存在诸如VTE等阻塞性生理状况。认知偏差可能会掩盖非典型表现的诊断。肺栓塞反应小组可以改善这些病例的管理，对于此类病例，及时诊断和治疗对于获得良好预后至关重要。
在基于缺乏典型体征排除肺栓塞时，应始终警惕认知偏差。对于主诉头晕的患者，区分眩晕与头晕或晕厥前症状至关重要。晕厥前症状可能是血流动力学显著的肺栓塞和移行性血栓的重要表现症状。
