pediatricjournalАрхив педиатрии и детской хирургииArchives of Pediatrics and Pediatric Surgery2949-46643033-6783НИКИ детства Минздрава Московской области10.31146/2949-4664-apps-3-1-68-75pediatricjournal-143Research ArticleКЛИНИЧЕСКИЙ СЛУЧАЙCLINICAL CASEТромбоэмболия легочной артерии у двух девочек-подростков. Клинические случаиPulmonary thromboembolism in two adolescent girls. Clinical caseshttps://orcid.org/0009-0000-6575-4151ДроздоваА. И.DrozdovaA. I.drozdovaL1@yandex.ruhttps://orcid.org/0000-0002-3888-5540ХиштиловаП. Б.HishtilovaP. B.pkhishtilova@mail.ruГБУЗ МО «Научно-исследовательский клинический институт детства» Министерства здравоохранения Московской областиРоссияResearch Clinical Institute of ChildhoodRussian Federation202521112025316976Copyright © Дроздова А.И., Хиштилова П.Б., 20252025Дроздова А.И., Хиштилова П.Б.Drozdova A.I., Hishtilova P.B.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.nikid.ru/jour/article/view/143

Актуальность. Тромбоэмболия легочной артерии (ТЭЛА) характеризуется острой перестройкой параметров центральной гемодинамики в большом и малом кругах кровообращения и является одним из частых жизнеугрожающих состояний среди взрослых пациентов. Несмотря на то что первое описание ТЭЛА было представлено фон Лешнером в 1861 году, до настоящего времени в педиатрической практике нет должной настороженности к подобному осложнению. Это объясняется не только отсутствием системных знаний о распространенности ТЭЛА в детской популяции, но и из-за стертости, а порой и нетипичной, в отличие от взрослого пациента, клинической картины. Неверная интерпретация имеющихся симптомов, ошибочная трактовка данных инструментальных методов исследования неизбежно приводят к неверному диагнозу: пневмония, сердечная недостаточность, дебют онкологического заболевания, что объясняет высокую летальность при ТЭЛА у детей.Цель. Демонстрация случаев ТЭЛА при наличии значимых факторов риска — прием пероральных контрацептивов, снижение уровня протеинов C и S у двух девочек-подростков.Материалы и методы. Представлены 2 случая клинически и/или инструментально подтвержденных эпизодов ТЭЛА у девушек 17 и 14 лет. ИМТ в одном и другом случае составил 25,9 и 25,15 кг/м2 соответственно. Среди инструментальных методов исследования были выполнены ЭКГ, трансторакальная ЭхоКГ, мультиспиральная компьютерная томография (МСКТ) с контрастированием. Лабораторная диагностика антифосфолипидного синдрома, анализ на тромбофилию были обязательным дополнением клиническому, биохимическому анализам крови и коагулограмме с определением уровня АТ-III и D-димера.Результаты. Среди клинических симптомов, имеющих диагностическую ценность в дебюте заболевания, были одышка, боли в области грудной клетки, кашель, кровохарканье. Ни в одном, ни в другом случае эпизод ТЭЛА не привел к повышению давления в легочной артерии, о чем свидетельствовали показатели давления в правом желудочке (ПЖ): 24 и 20 мм рт. ст. соответственно. МСКТ с контрастированием подтвердила диагноз субмассивной ТЭЛА и признаки инфаркт-пневмонии в одном и другом случаях. УЗДГ не обнаружила источника ТЭЛА в сосудах нижних конечностей и малого таза ни у одной из девушек. Прием пероральных контрацептивов в одном случае и снижение уровня протеинов С и S в другом явились значимыми факторами развития ТЭЛА. Лечебная тактика заключалась в назначении низкомолекулярных гепаринов (НМГ) с переходом на непрямые антикоагулянты: апиксабан и варфарин соответственно. Выполненная через месяц МСКТ свидетельствовала о положительной динамике заболевания, но не полном восстановлении воздушности легочной ткани. Терапия непрямыми антикоагулянтами была продолжена.Заключение. Частота встречаемости ТЭЛА в детской популяции реже, чем у взрослых, но это не снижает уровня значимости данного грозного осложнения в педиатрической практике. Центральные венозные катетеры, септические осложнения, длительная иммобилизация, шунтированная гидроцефалия, онкология, ожирение являются наиболее вероятными причинами ТЭЛА у детей, как и у взрослых пациентов. Прием оральных контрацептивов и наследственные тромбофилии в двух наших наблюдениях свидетельствуют о других не менее очевидных причинах возникновения ТЭЛА у детей подросткового возраста.

Background. Pulmonary embolism (PE) is characterized by an acute alteration of central hemodynamic parameters in the systemic and pulmonary circulation, representing a common life-threatening condition among adult patients. Although Josef von Löschner first described PE in 1861, there remains a lack of knowledge of this complication in pediatric practice. This gap is related not only to a lack of systematic knowledge about the prevalence of PE in the pediatric population, but also to the vagueness and sometimes atypical nature of its clinical presentation, unlike in adult patients. Misinterpretation of existing symptoms and incorrect interpretation of instrumental examination data inevitably lead to incorrect diagnoses of pneumonia, heart failure, or the onset of cancer, which explains the high mortality rate of PE in children.Objective. To demonstrate cases of pulmonary embolism (PE) in the presence of significant risk factors — oral contraceptive use and decreased levels of proteins C and S — in two adolescent girls.Materials and methods. We present two cases of clinically and/ or instrumentally confirmed episodes of PE in adolescent female patients aged 17 and 14 years. The BMI was 25.9 and 25.15 kg/m², respectively. Instrumental examinations included ECG, transthoracic echocardiography, and contrast-enhanced MSCT. Laboratory testing for antiphospholipid syndrome and thrombophilia testing were mandatory additions to clinical and biochemical blood tests, as well as a coagulogram with determination of ATIII and D-dimer levels.Results. Clinical symptoms of diagnostic value at the onset of the disease included shortness of breath, chest pain, cough, and hemoptysis. In neither case did the PE episode result in an increase in pulmonary artery pressure, as evidenced by right ventricular pressure readings of 24 and 20 mmHg, respectively. Contrast-enhanced CT confirmed the diagnosis of submassive PE and signs of infarction pneumonia in both cases. Doppler ultrasound did not detect a source of PE in the vessels of the lower extremities or pelvis in either patient. Oral contraceptive use in one case and decreased protein C and S levels in the other were significant factors in the development of PE. The respective treatment consisted of low-molecular-weight heparins (LMWH) followed by indirect anticoagulants: apixaban and warfarin, respectively. A one-month follow-up MSCT showed improvement in the disease but not complete restoration of the lung airflow. Indirect anticoagulant therapy was continued.Conclusion. The incidence of pulmonary embolism in children is lower than in adults, which this does not diminish the significance of this serious complication in pediatric practice. Central venous catheters, septic complications, prolonged immobilization, shunted hydrocephalus, cancer, and obesity are the most likely causes of PE in children, similar to adults. Oral contraceptive use and hereditary thrombophilia in two of our cases suggest other equally obvious causes of PE in adolescents.

тромбоэмболия легочной артериитромбоэмболия легочной артерии у детей и подростковпероральные контрацептивные препаратыврожденные тромбофилииpulmonary embolismpulmonary embolism in children and adolescentsoral contraceptiveshereditary thrombophiliaReferencesGesammelte Abhandlungen zur wissenschaftlichen Medizin. Front Cover. Rudolf Virchow, Virchow. Meidinger John & Josep, 1856; 1024 p.Gesammelte Abhandlungen zur wissenschaftlichen Medizin. Front Cover. Rudolf Virchow, Virchow. Meidinger John & Josep, 1856; 1024 p.Riedel M. Acute pulmonary embolism: pathophysiology, clinical presentation, and diagnosis. Heart. 2001;85:229–240.Riedel M. Acute pulmonary embolism: pathophysiology, clinical presentation, and diagnosis. Heart. 2001;85:229–240.von Löschner J.W.F. Phlebitis venae cruralis sinistrae, periet myocarditis, embolia et oedema pulmonum. Jahrb f Kenderh (1861) 4:6.2. J.R. Buck, R.H. Connors, W.W. Coon et al. Pulmonary embolism in children. Journal of Pediatric Surgery. June 1981;16(3):385–391.von Löschner J.W.F. Phlebitis venae cruralis sinistrae, periet myocarditis, embolia et oedema pulmonum. Jahrb f Kenderh (1861) 4:6.2. J.R. Buck, R.H. Connors, W.W. Coon et al. Pulmonary embolism in children. Journal of Pediatric Surgery. June 1981;16(3):385–391.Andrew M., David M., Adams M., Ali K., Anderson R., Barnard D., et al. Venous thromboembolic complications (VTE) in children: first analyses of the Canadian Registry of VTE. Blood. 1994;83:1251–1257.Andrew M., David M., Adams M., Ali K., Anderson R., Barnard D., et al. Venous thromboembolic complications (VTE) in children: first analyses of the Canadian Registry of VTE. Blood. 1994;83:1251–1257.Biss T.T., Brandão L.R., Kahr W.H., Chan A.K., Williams S. Clinical features, and outcome of pulmonary embolism in children. Br J Haematol. 2008;142:808–818.Biss T.T., Brandão L.R., Kahr W.H., Chan A.K., Williams S. Clinical features, and outcome of pulmonary embolism in children. Br J Haematol. 2008;142:808–818.van Ommen C.H., Heijboer H., Büller H.R., et al. Venous thromboembolism in childhood: a prospective two-year registry in the Netherlands. J Pediatr. 2001;139:676–681.van Ommen C.H., Heijboer H., Büller H.R., et al. Venous thromboembolism in childhood: a prospective two-year registry in the Netherlands. J Pediatr. 2001;139:676–681.Stein P.D., Kayali F., Olson R.E. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004;145:563–565.Stein P.D., Kayali F., Olson R.E. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004;145:563–565.Dijk F.N., Curtin J., Lord D., Fitzgerald D.A. Pulmonary embolism in children. Paediatr Respir Rev. 2012;13:112–122.Dijk F.N., Curtin J., Lord D., Fitzgerald D.A. Pulmonary embolism in children. Paediatr Respir Rev. 2012;13:112–122.Ariel de Siqueira Lira L., Celeste D.M., Garanito M., et al. Pulmonary embolism in pediatrics: A 10year experience from a tertiary center in Brazil. Hematol transfus cell ther. 2023;45(S2):85−90.Ariel de Siqueira Lira L., Celeste D.M., Garanito M., et al. Pulmonary embolism in pediatrics: A 10year experience from a tertiary center in Brazil. Hematol transfus cell ther. 2023;45(S2):85−90.Wells P.S., Ginsberg J.S., Anderson D.R. et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997.Wells P.S., Ginsberg J.S., Anderson D.R. et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997.Klok F.A., Mos I.C.M., Nijkeuter M., et al. Simplifi cation of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008; 168:2131–2136.Klok F.A., Mos I.C.M., Nijkeuter M., et al. Simplifi cation of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008; 168:2131–2136.Kline J.A., Courtney D.M., Kabrhel C., et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Th romb Haemost. 2008; 6:772–780.Kline J.A., Courtney D.M., Kabrhel C., et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Th romb Haemost. 2008; 6:772–780.Stein P.D., Kayali F., Olson R.E. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004;145:563–565.Stein P.D., Kayali F., Olson R.E. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004;145:563–565.Agha B.S., Sturm J.J., Simon H.K., et al. Pulmonary embolism in the pediatric emergency department. Pediatrics. 2013;132:663–667.Agha B.S., Sturm J.J., Simon H.K., et al. Pulmonary embolism in the pediatric emergency department. Pediatrics. 2013;132:663–667.Biss T.T. Pulmonary embolism in childhood: how can we be sure not to miss it? Arch Dis Child. 2018;103:814–816.Biss T.T. Pulmonary embolism in childhood: how can we be sure not to miss it? Arch Dis Child. 2018;103:814–816.Marcì M., Castiglione M.C., Sanfi lippo N. Pulmonary embolism in children: a report of two cases. J Cardiol Curr Res. 2016;5(3).Marcì M., Castiglione M.C., Sanfi lippo N. Pulmonary embolism in children: a report of two cases. J Cardiol Curr Res. 2016;5(3).Stein P.D., Kayali F., Olson R.E. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004;145(4):563–565.Stein P.D., Kayali F., Olson R.E. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004;145(4):563–565.Maggio A., Altieri L., Pantaleo D., Grignani M., et al. Pulmonary embolism in children, a real challenge for the pediatrician: a case report and review of the literature. Acta Biomed. 2022;93(3):1–6.Maggio A., Altieri L., Pantaleo D., Grignani M., et al. Pulmonary embolism in children, a real challenge for the pediatrician: a case report and review of the literature. Acta Biomed. 2022;93(3):1–6.Buck J.R., Connors R.H., Coon W.W., Weintraub W.H., Wesley J.R., Coran A.G. Pulmonary embolism in children. J Pediatr Surg. 1981;16:385–391.Buck J.R., Connors R.H., Coon W.W., Weintraub W.H., Wesley J.R., Coran A.G. Pulmonary embolism in children. J Pediatr Surg. 1981;16:385–391.Urooj Zaidi A., Hutchins K.K. and Rajpurkar M. Pulmonary embolism in Children. Frontiers in Pediatrics. August 2017;5:1–8.Urooj Zaidi A., Hutchins K.K. and Rajpurkar M. Pulmonary embolism in Children. Frontiers in Pediatrics. August 2017;5:1–8.Brandao L.R., Labarque V., Diab Y., Williams S., et al. Pulmonary embolism in children. Semin Th romb Hemost. 2011;37:772–785.Brandao L.R., Labarque V., Diab Y., Williams S., et al. Pulmonary embolism in children. Semin Th romb Hemost. 2011;37:772–785.Bernstein D., Coupey S., Schonberg S.K. Pulmonary embolism in adolescents. Am J Dis Child. 1986;140:667–671.Bernstein D., Coupey S., Schonberg S.K. Pulmonary embolism in adolescents. Am J Dis Child. 1986;140:667–671.Rajpurkar M., Warrier I., Chitlur M., Sabo C., Frey M.J., Hollon W., et al. Pulmonary embolism-experience at a single children’s hospital. Thromb Res. 2007;119:699–703.Rajpurkar M., Warrier I., Chitlur M., Sabo C., Frey M.J., Hollon W., et al. Pulmonary embolism-experience at a single children’s hospital. Thromb Res. 2007;119:699–703.McGinn S., White P.D. Acute cor pulmonale resulting from pulmonary embolism. J Am Med Assoc 1935;104:1473.McGinn S., White P.D. Acute cor pulmonale resulting from pulmonary embolism. J Am Med Assoc 1935;104:1473.Gleason M.M., White M.G., Myers J.L. Echocardiographic diagnosis of pulmonary embolism in childhood. J Am Soc Echocardiogr. 1995;8:100–102.Gleason M.M., White M.G., Myers J.L. Echocardiographic diagnosis of pulmonary embolism in childhood. J Am Soc Echocardiogr. 1995;8:100–102.Stein P.D., Fowler S.E., Goodman L.R., et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317–2327.Stein P.D., Fowler S.E., Goodman L.R., et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006;354(22):2317–2327.Thacker P.G., Lee E.Y. Pulmonary embolism in children. AJR Am J Roentgenol. 2015;204:1278–1288.Thacker P.G., Lee E.Y. Pulmonary embolism in children. AJR Am J Roentgenol. 2015;204:1278–1288.Hiroyuki Tajima, Tadashi Kaneshiro, Naoko Takenoshita, et al. Endovenous Treatment for Acute Massive Pulmonary Thromboembolism. Annals of Vascular Diseases, Advance Published Date: October 30, 2017:1–6.Hiroyuki Tajima, Tadashi Kaneshiro, Naoko Takenoshita, et al. Endovenous Treatment for Acute Massive Pulmonary Thromboembolism. Annals of Vascular Diseases, Advance Published Date: October 30, 2017:1–6.Dellas C., Puls M., Lankeit M., et al. Elevated hearttype fatty acid-binding protein levels on admission predict an adverse outcome in normotensive patients wiTh acute pulmonary embolism. J Am Coll Cardiol. 2010;55:2150–2157.Dellas C., Puls M., Lankeit M., et al. Elevated hearttype fatty acid-binding protein levels on admission predict an adverse outcome in normotensive patients wiTh acute pulmonary embolism. J Am Coll Cardiol. 2010;55:2150–2157.Lankeit M., Friesen D., Aschoff J., et al. Highly sensitive troponin T assay in normotensive patients wiThacute PE in Children. Eur Heart J. 2010;31:1836–1844.Lankeit M., Friesen D., Aschoff J., et al. Highly sensitive troponin T assay in normotensive patients wiThacute PE in Children. Eur Heart J. 2010;31:1836–1844.Manco-Johnson M.J., Grabowski E.F., Hellgreen M., et al. Laboratory testing for thrombophiliain pediatric patients. On behalf of the Subcommittee for Perinatal and Pediatric Thrombosis of the Scientifi c and Standardization Committee of the International Society of Thrombosis and Haemostasis (ISTH). Thromb Haemost. 2002;88:155–156.Manco-Johnson M.J., Grabowski E.F., Hellgreen M., et al. Laboratory testing for thrombophiliain pediatric patients. On behalf of the Subcommittee for Perinatal and Pediatric Thrombosis of the Scientifi c and Standardization Committee of the International Society of Thrombosis and Haemostasis (ISTH). Thromb Haemost. 2002;88:155–156.

The authors declare that there are no conflicts of interest present.