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A 77-year-old woman presented to the emergency department after the shortness of breath and chest pain she had been experiencing for a week suddenly worsened. She had recently received treatment for suspected pneumonia or pleurisy and had undergone cardiac catheterization (findings were reported as normal) for nonspecific ischemic changes on electrocardiography. The patient described the pain as pleuritic with pressure sensation over her chest. She denied any symptoms of deep venous thrombosis, fever, chills, cough, hemoptysis, or sputum production; any recent surgery, prolonged immobilization, or any personal or family history of deep venous thrombosis, pulmonary embolism, or clotting disorders; and any history of smoking tobacco, drinking alcohol, or using recreational drugs. The patient's history was remarkable for hypertension, hyperlipidemia, hypothyroidism, acid reflux, and melanoma treated 20 years earlier. Physical examination findings were unremarkable except for mild bilateral pedal edema. No calf tenderness was noted. Laboratory values were normal except marginally elevated troponin levels. Electrocardiography showed slightly prolonged QTc and T-wave inversion across precordial leads. Chest computed tomography with contrast medium revealed massive bilateral pulmonary emboli (short arrows) and an 8-cm intracardiac thrombus traversing patent foramen ovale (PFO) (with each limb, 3-4 cm, in the left and right atrium [long arrow]). Transthoracic echocardiography of the heart confirmed the findings on computed tomography (supplemental video online linked to this article). Anticoagulation was initiated and the patient referred to cardiothoracic surgery for emergent clot removal.
A well-known cause of paradoxical emboli, PFO can cause stroke, limb ischemia, visceral infarction, or pulmonary embolism. Primary care physicians and hospitalists should have a high index of suspicion for detecting PFO during work-up for cryptogenic stroke.
An earlier version of this article appeared Online First.