Pulmonary thromboembolism in two adolescent girls. Clinical cases

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 signifi-cance 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.

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