Mödl B, Reuter N, Pfafferott C, Wirtzfeld A
Medizinische Klinik I, Klinikum Ingolstadt.
Dtsch Med Wochenschr. 1996 Apr 26;121(17):556-60. doi: 10.1055/s-2008-1043040.
A 55-year-old woman developed increasing shortness of breath and breath-independent pain in the left lower chest. 20 years previously she had had an episode of pulmonary embolism and 10 years previously a central venous thrombosis in the left eye. No cause of the increased thrombogenesis had been found. On admission she had resting dyspnoea but a stable circulation. On auscultation the breath sounds were diminished over the left base and there was a diastolic murmur over the pulmonary area with an accentuated second sound. There was also marked tenderness below the left costal margin. Recurrent pulmonary embolism or left-sided pleuropneumonia was suspected.
Arterial blood gases (without additional oxygen) showed severe hypoxaemia (pO2 42.3 mm Hg, pCO2 27.8 mm Hg, pH 7.455, oxygen saturation 80.5%). Transthoracic and transoesophageal echocardiography showed normal left ventricular dimensions, right atrial and ventricular dilatation, and an atrial septal aneurysm with a right to left interatrial shunt. Right heart catheterisation demonstrated severe pulmonary hypertension. Sonography, computed tomography and scintigraphy revealed multiple splenic infarcts.
Heparinisation was instituted (partial thromboplastin time 70-90 s) and overlapping oral anticoagulation to a Quick value of 20%. Subsequently the calcium antagonist felodipine (15 mg daily) was given. The mean pulmonary artery pressure was 61 mm Hg before and 57 mm Hg after treatment.
Splenic infarction resulting from paradoxical embolisation is rare, but should be routinely considered in the presence of thromboembolic phenomena.
一名55岁女性出现进行性气短及左下胸部与呼吸无关的疼痛。20年前她曾有过一次肺栓塞发作，10年前左眼发生过一次中心静脉血栓形成。未发现血栓形成增加的原因。入院时她有静息性呼吸困难，但循环稳定。听诊时左肺底部呼吸音减弱，肺动脉区有舒张期杂音，第二心音亢进。左肋缘下也有明显压痛。怀疑为复发性肺栓塞或左侧胸膜炎肺炎。
动脉血气分析（未吸氧）显示严重低氧血症（pO₂ 42.3 mmHg，pCO₂ 27.8 mmHg，pH 7.455，氧饱和度80.5%）。经胸和经食管超声心动图显示左心室大小正常，右心房和心室扩张，以及房间隔瘤伴右向左心房分流。右心导管检查显示严重肺动脉高压。超声检查、计算机断层扫描和闪烁扫描显示多发脾梗死。
开始肝素化（部分凝血活酶时间70 - 90秒）并重叠口服抗凝使Quick值达到20%。随后给予钙拮抗剂非洛地平（每日15毫克）。治疗前平均肺动脉压为61 mmHg，治疗后为57 mmHg。
反常栓塞导致的脾梗死罕见，但在存在血栓栓塞现象时应常规考虑。
