key: cord-1026485-7e7tsnya
authors: Williamson, Jonathan; Brown, Joe; Arthur, Jason
title: Reprint of: Pulmonary Embolism with Hampton Hump in COVID-19 patient
date: 2022-04-12
journal: Dis Mon
DOI: 10.1016/j.disamonth.2022.101386
sha: abf2ec97e31ae1c326d4363d9481243daa03c376
doc_id: 1026485
cord_uid: 7e7tsnya

nan

Pulmonary embolism (PE) is a life-threatening condition with numerous causes and various presentations. Symptoms of PE include shortness of breath, pleuritic chest pain, cough, or hemoptysis. There is a broad spectrum of presentation of PE, from minimal symptoms to profound shock or cardiac arrest. 1 A massive PE is defined as one that presents with hemodynamic instability, while a low risk PE is seen in the setting of normal vital signs. In the intermediate group, or a submassive PE, patients may present with borderline blood pressure and evidence of ventricular remodeling. 1 Diagnostic evaluation for a suspected PE in a hemodynamically stable patient includes a determination of pre-test probability using Wells' Criteria, Geneva Criteria, or clinical gestalt. Patients with a low to moderate pre-test probability often undergo testing with a d-dimer. Those with either an elevated d-dimer or high pre-test should undergo diagnostic imaging with either computed tomography pulmonary angiography (CTPA), a V/Q scan, or pulmonary angiography. 1 Chest radiography is routinely obtained in patients presenting with dyspnea or chest pain; however, it has poor test characteristics for the diagnosis of PE. Therefore, its utility is typically in the diagnosis of other more common diseases rather than to diagnose or exclude PE. Rarely, a significant pulmonary artery obstruction may lead to a wedge shaped infarct that is visible on chest radiograph, a sign known as Hampton's Hump. 1 The lungs are normally protected from infarction by a dual blood supply from the pulmonary and bronchial arteries. As result, Hampton's Hump is a low sensitivity marker for PE that occurs in up to 36% of these patients. 2 The presence of a Hampton Hump (image 1) should further increase suspicion of a PE. The patient in this case presented with shortness of breath and chest pain several weeks after diagnosis of SARS-CoV-2 and pneumonia. COVID-19, the disease process that is caused by SARS-CoV-2, is thought to be a disproportionately prothrombotic condition relative to the hypercoagulability of critical illness. 2

A 74 year old female with a history of diabetes, hypertension, end-stage renal disease, and seizures presented to the ED via ambulance due to altered mental status, shortness of breath, and chest pain. She recently was admitted for pneumonia at another facility, during which time she tested positive for SARS-Cov-2/COVID-19. Since discharge she had missed multiple dialysis appointments and had become progressively more confused. Family reported that she had suffered from similar episodes of confusion in the past which were attributed to uremic encephalopathy and improved with dialysis. Due to the patient's confusion, she was unable to provide a flowing description of her chest pain and dyspnea. On exam she was alert and oriented but slow to answer questions. She was hypertensive, mildly tachycardic, afebrile, with normal oxygen saturation on room air. Her cardiovascular exam revealed a sinus tachycardia with no murmurs, rubs or gallops. Pulmonary exam showed rales with normal effort. Bilateral lower extremity edema was present. Other examinations were unremarkable. Chest radiograph showed signs of a peripherally based, wedged shaped consolidation near the right middle lobe which was concerning for either a right middle lobe pneumonia or a Hampton Hump (image 1). In light of her recent hospitalization, diagnosis of SARS-CoV-2/COVID-19, and concerning radiograph, a CTPA was ordered to delineate if this was a pneumonia or a pulmonary infarct. CTPA demonstrated bilateral pulmonary embolism with clot burden (image 2) and infarction with possible overlying infection (image 3). She was started on broad-spectrum antibiotics for hospital associated pneumonia, anticoagulated with heparin, and admitted to the hospital for further care. 

Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. UpToDate

Radiographic feature of PE: Hampton's Hump

Coronavirus disease 2019 (COVID-19)