A 58-year-old man with pleuritic chest pain and an indeterminate lung scan had normal originates of Duplex ultrasound studies of the lower limbs and a normal pulmonary angiogram.

A 58-year-old man with pleuritic chest pain and an indeterminate lung scan had normal originates of Duplex ultrasound studies of the lower limbs and a normal pulmonary angiogram. returning symptoms led to repeated pulmonary angiography and a diagnosis of pulmonary embolism. This case emphasizes the possibility of missing an initial, or developing a posterior pulmonary embolism despite a normal angiogram and reinforces the ne for serial studies if a noninvasive strategy for the diagnosis of pulmonary embolism is to be employed

Pulmonary embolism is a public often unexpected, cause of death partly fit to difficulty in making the clinical diagnosis.[1] Studies examining the sensitivity and specificity of various proceedings for making the diagnosis of pulmonary embolus have used pulmonary angiography as the "gold standard."[2,3] In the one and the other of these studies, a limited number of patients with an initially normal angiogram were subsequently place to have evidence of pulmonary embolism at autopsy. Other studies have verified the incident of false-negative angiograms in patients with clinically suspected pulmonary embolism.[4-7] However, the diagnosis of pulmonary embolus was either made at autopsy[4,5] or les than optimal technique was used in performing the pulmonary angiogram.[6,7] We report herein the case of a 58-year-old man with an initial false-negative pulmonary angiogram despite the use of praiseed techniques.[3]

CASE REPORT

A 58-year-old man neared with a 1-day history of left-sided pleuritic chest pain and a small quantity of blood-streaked sputum the same month earlier, he presented to another hospital with right-sided pleuritic chest pain and a nonproductive cough A presumptive diagnosis of pneumonia was made and his symptoms resolv completely after 1 week of oral penicillin therapy. onward current examination, temperature was 372 [degrees] C legumes was 84 beats/min, and respiratory rate was 18 breaths/min. The patient was not in any distress and findings from the chest examination were within normal limits. Laboratory investigations showed the following: hemoglobin, 140 g/L; WBC hold 8.3 X [10.sup.9]/L; and creatine kinase, 50 [mu]/L Arterial kindred gas values on room air revealed a pH of 746 [PaCO.sub.2] of 36 mm Hg [PaO.sub.2] of 80 mm Hg and oxygen saturation of 96 percent The alveolar-arterial oxygen gradient was 25 The chest radiograph revealed consolidation of the posterobasal portion of the left lower lobe. A ventilation-perfusion lung scan showed a subsegmental, mismatched perfusion imperfection in the right posterobasal portion and a segmental, matched, ventilation and perfusion want in the left posterobasal section that also matched the chest radiograph defect

The patient was admitted to hospital and a Duplex ultrasound examination of the lower extremities failed to point out any evidence for deep venous thrombosis. in succession the following day, 2 days after the attack of symptoms, a pulmonary angiogram was performed (Fig 1) Bilateral selective lower lobe arterial injections were carried abroad with sequential cut films in the two the frontal and oblique planes. Atelectasis in the left lower lobe was noted still no evidence of pulmonary embolism was place The patient's condition improved spontaneously without any specific therapy and he was discharged domestic circle 3 days after admission to hospital. When seen 5 days later, he was asymptomatic and his chest radiograph was normal.

He replyed to the emergency department 10 days later when he unexpectedly developed severe right-sided pleuritic pain. Physical examination revealed that temperature was 365 [degrees] C throb rate was 103 beats/min, and respiratory rate was 18/min. He appeared well if it be not that tenderness was noted over the right lower chest wall associated with diminished breath unimpaireds on auscultation and decreased tactile fremitus. Laboratory investigations revealed the following: hemoglobin, 144 g/L; WBC estimate 13.0 X [10.sup.9]/L, with 768 percent granulocytes, 183 percent lymphocyte and 49 percent monocytes. Arterial life-current gases on room air revealed a pH of 742 [PaCO.sub.2] of 38 mm Hg [PaO.sub.2] of 78 mm Hg and oxygen saturation of 96 percent The alveolar-arterial oxygen gradient was 24 A chest radiograph showed decreased lung contortions and airspace disease in the right lower lobe and a small right pleural effusion.

A ventilation-perfusion lung scan performed onward the same day revealed a matched perfusion and ventilation imperfection in the right posterobasal portion corresponding to the chest radiograph abnormality.

brace days later, the pulmonary angiogram was repeated. Bilateral selective lower lobe arteriograms were performed with as well-as; not only-but also; not only-but; not alone-but frontal and oblique views, one time again using sequential cut films. This time, pulmonary embolism was diagnosed upon the basis of a filling blemish in the right lower lobe arteries (Fig 2) seen upon each view. The patient was started in succession a regimen of heparin and warfarin. Three days following the angiogram, a Duplex ultrasound examination of as well-as; not only-but also; not only-but; not alone-but lower extremities revealed venous thrombosis partially occluding the lumen of the right usual femoral vein. The patient was discharged from the hospital onward a regimen of warfarin and remains well after 3 month of therapy.

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