Case Presentation:
A 29-year-old female presented to the hospital with left-sided pleuritic chest pain that started in the morning. The patient described the pain as a pressure-like sensation with no radiation, 6/10 in intensity, exacerbated by deep breathing without relief. She reported shortness of breath with deep inspiration only. The patient denied having headaches, dizziness, nausea/vomiting, fever or chills, a cough, or recent travel. She reported heavy menstrual bleeding and severe IDA, requiring iron infusion in the past, the last being in 2021 during her second pregnancy. She had a history of C-sections. The patient had no history of COVID-19 infection. The patient was not taking any oral contraceptive pills.
On the physical examination, the patient was alert, oriented, and in mild distress, had a blood pressure of 120/76, heart rate of 73 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on room air and had conjunctival pallor and koilonychia. Heart and lung sounds were within normal limits. The abdomen was soft, non-distended, and non-tender. There was no erythema or edema on the bilateral lower extremity examination. Initial laboratory examination showed a decrease in international normalized ratio to 1.0, decrease in PT to 10.5, APTT was within normal limit, D- Dimer Quant was elevated- 2.50 (normal range- 0.00- 0.49 mg/L FEU), Due to active thromboses, protein C and S and mixing investigations were inconclusive. It also showed RBC (red blood cells)- 4.06, hemoglobin 7.7, (normal range-12.0-16.0 g/dl), hematocrit- 27.0 (normal range-37.0-47.0 g/dl), MCV (mean corpuscular volume)- 66.5 (normal range-81.0-99.0 fl), MCH (mean corpuscular hemoglobin)- 19.0 (normal range-27.0-31.0 pg), MCHC (mean corpuscular hemoglobin concentration)- 28.5 (normal range-33.0-37.0 g/dl), RDW (red cell distribution width)- 19.1 (normal range-0-14.5%),WBC- 13.6 and Platelet- 706,000 (normal range 150,000 -400,000 mL). CMP (comprehensive metabolic panel) and renal function tests were normal. Laboratory results were also significant for nucleated RBC-0.0, slight polychromasia, moderate hypochromasia, moderate microcytosis, and a few teardrop cells (a few schistocytes). Iron profile showed serum iron - 9 ug/dL (normal range- 50-170 ug/dL), serum ferritin - 15 ug/L (normal range- 41-400 ug/L), total iron binding capacity- 480 ug/dL (normal range- 250-450 ug/dL), transferrin saturation - 3% (normal range 15% to 50%). The pregnancy test was negative. In Figure 1, the ECG of the patient showed sinus arrhythmia at a rate of 61, no ST elevation, and no ectopy. The chest x-ray was normal. CTA chest showed subsegmental pulmonary embolism in the left lower lobe with adjacent pulmonary infarct/hemorrhage.