Floating pulmonary embolus: unusual cause of recurrent syncope

Pulmonary embolism presenting as syncope: case report and review of the literature

Syncope as an initial presentation of pulmonary embolism occurs in about 10% of patients. A 68-year-old woman was admitted to the hospital with syncope. A right lower lobe infiltrate was found on a chest x-ray film, and results of a ventilation-perfusion scan were interpreted to mean that a high probability of pulmonary embolism existed. Other causes of syncope were excluded. A Doppler scan of the lower extremities revealed deep venous thrombosis. Intravenous heparin was administered, and then an inferior vena cava filter was placed to prevent pulmonary embolism from recurring. The patient has been well for 16 months since that episode. A review of 20 case reports in the literature of 10 women and 10 men with pulmonary embolism presenting as syncope revealed that female patients were younger than male patients and that the outcome was fatal in 40% of all cases. Syncope as a presenting symptom of pulmonary embolism is difficult to diagnose. Physicians must be vigilant with patients who have syncope, because this symptom may be the "forgotten sign" of life-threatening pulmonary embolism. The need for prompt diagnosis is clear, because with appropriate treatment the majority of patients may survive.

Acute pulmonary embolism triggered by the act of defecation

Pulmonary embolism associated with the act of defecation has not been previously well described. Recently, we reported our experience with four patients who presented to us over a 12-month period with syncope, near syncope, or sudden death following the act of defecation. In all four cases, acute pulmonary embolism was shown to be the etiology of the defecation-associated events. A retrospective chart review of all patients with the diagnosis of pulmonary embolism at our institution over a three-year period yielded five additional patients with the diagnosis of defecation-associated pulmonary embolism. These nine patients accounted for 6.8 percent of all patients with a discharge diagnosis of pulmonary embolism seen at our institution during the three-year study period. Six of the nine patients died from their defecation-associated pulmonary embolism. These six deaths accounted for 25 percent of all deaths from pulmonary embolism seen at our institution during the study period. Based on our experience, we suggest that the act of defecation may trigger the development of acute pulmonary embolism in some patients with deep vein thrombosis.

Syncope as a premonitory sign of fatal pulmonary embolism. Two case reports

Two patients suddenly died of massive pulmonary embolism 3 weeks after hip surgery. In retrospect, several episodes of syncope starting during the first postoperative week were recognized as premonitory signs of the fatal outcome.