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.