Case Report
A 44 years old male a Tanzanian tourist first time hiking Mt Kilimanjaro. He had no significant past medical history and had not used any prophylaxis before hiking the mountain. On the 4thday of ascending on a route that takes six days to summit, at the height of 4775m he developed severe difficulty in breathing. An initial assessment done by the professional guide reported he was breathlessness, having chest pain weak and had a low oxygen saturation of 38% in room air. He was immediately kept on oxygen and rapid descent was initiated by the guides using a customized single wheel canvas bed to a level of 2300 meters where there was a standby ambulance which shuttled him to a health facility. At the base of the mountain the saturation raised to 83% on supplemental oxygen with a mild noted improvement of the symptoms. No history of confusion, loss of consciousness or fever that was reported.
At arrival to the hospital the patient was still dyspneic, afebrile and on oxygen supplementation with saturation of 86 % in room air. When titrating the oxygen level to five liters of oxygen on rebreather face mask, saturation reached 98%. The rest of the vital signs were; BP- 130/77 mmHg, PR-103bpm, RR- 24 cycles/minute, T- 36.7C. Systemic examination of the chest revealed fine crepitation at the mid zone and base of the lungs on bilateral auscultation, other systems were essentially normal.
The investigations done were chest X-ray which showed bilateral lower lobe infiltrates more on the left lung features suggestive of pulmonary edema, Electrocardiogram (ECG) done showed sinus tachycardia, CBC showed normal leukocyte count with hemoglobin of 12.9 g/dl, and hematocrit of 37%, D-dimer was raised to 8.5 UgFEU/ml other biochemistries including Creatinine and Lipid profile were all normal however Covid-19 wasn’t tested because it seemed unlikely. The patient was kept on oxygen and was also initiated on Nifedipine 10mg per oral twice a day. The patient was nursed in the ward.
On the 3rd day in the ward the patient was still dyspneic and was still saturating at 91% in room air and 95% on 8 liters of oxygen. An ECG was done again and showed features of right heart straining, an ECHO was done with normal findings, and chest CT angiography was ordered and revealed a filling defect in the right upper and bilateral lower lobe pulmonary arteries suggestive of pulmonary embolism (Figure 01). The patient was initiated on low molecular heparin (enoxaparin) 60mg subcutaneous twice a day for 5 days and remarkably improved and was discharged after 4 days with warfarin 5mg per oral od and He was instructed to come back to the health facility after 2 weeks for follow up visit and checkup.