CONGRESS ABSTRACT

An 86 years old man, with hypertensive heart disease, chronic obstructive pulmonary disease, pulmonary emphysema, chronic kidney disease, wearer of pacemaker, was admitted with dyspnea and fever. He had SBP 160/80 mmHg, HR 77 bpm, SO2 96% in AA, RR 27 rpm, TC 37.5°. The arterial blood gas analysis showed an acute respiratory alkalosis (pH 7,52; pCO2 26 mmHg; pO2 86 mmHg; HCO3- 21 mmol/L; Lac 1.0 mmol/L). On the blood test neutrophilia, PLT 150.000/uL; increased levels of C-reactive protein, D-dimer, NT-PROBNP. The electrocardiogram showed sinus rhythm (HR 93 bpm), left axis deviation, ST segment abnormalities. An estimated pulmonary artery pressure (PAPs) of 35 mmHg, signs of right ventricular dysfunction (RVD), right atrial thrombus (RAT) on the echocardiogram. RAT can be found in 4-18% of patients hospitalized for Pulmonary Embolism (PE). These patients have a higher mortality risk, as the thrombus can trigger a massive PE. Our patient with RAT and Wells score of 4.5 underwent CT pulmonary angiography that showed slight interstitial thickening a segmental PE and a suspected lung lesion. So, He had AT, PE at intermediate mortality risk (PESI score 116, class III, RVD, negative TNI but increased NT-pro-BNP). No randomized controlled trials are currently available for AT. We performed infection evaluation for unknown origin fever with all recommended laboratory tests and cultures, and abdominal ultrasound. All tests came back negative. The patient 3 weeks before admission had had an annular skin lesion on the front of his right leg. IgG and IgM antibodies for Borrelia Burgdorferi were performed and the diagnosis of Borreliosis was made. The antimicrobial treatment with doxycycline was started. In our patient, we considered both the type of non-mobile thrombus, the age, the presence of renal failure, comorbidities and we chose therapy based on fundaparinux 7,5 mg for 1 week and then we started the therapy with edoxaban 60 mg once a day. In conclusion, the strange dyspnea of the patient was caused by multiple diseases at the same time: Borrelia pneumonia; Pulmonary Embolism, suspected lung cancer and pulmonary emphysema. After some days the fever was over with partial relief of symptoms. At discharge the NT-pro-BNP values decreased, on the echocardiogram, even if the presence of atrial thrombosis remained, the ventricular function had improved and our patient was discharged with the indication to carry out an outpatient evaluation and follow-up of PE.