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BMJ Case Rep. 2010; 2010: bcr0320102793.
Published online 2010 November 5. doi:  10.1136/bcr.03.2010.2793
PMCID: PMC3029575
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‘Silent’ but massive bilateral pulmonary embolic disease


An 80-year-old man presented to the facility, describing 6 months of increasing shortness of breath. Prior to admission, he had been bed bound for 5–7 days due to a chest infection. Observations revealed a pulse 79/min, blood pressure 119/79 mm Hg and a respiratory rate of 16/min. Oxygen saturation levels were 95% on room air, and he was apyrexial. Aside from a 5-cm raised, jugular-venous pressure and left-sided basal crepitations, physical examination was unremarkable. The full blood count, inflammatory makers and coagulation profile were normal. An ECG showed atrial fibrillation at 85 beats/min, and the chest x-ray taken was normal.

An echocardiogram showed a large, mobile, lobulated, right-atrial mass (figure 1), an ejection fraction of 41–50%, but no wall-motion abnormalities. The right ventricle was not dilated, but the pulmonary pressure was elevated at 46 mm Hg + jugular venous pulse. Treatment dose of low-molecular-weight heparin was initiated. The following day, a CT pulmonary angiogram showed large, bilateral, pulmonary emboli involving the bifurcation of both pulmonary trunks (figure 2). This scan showed no evidence of the right-atrial mass, which was also confirmed on repeat echo.

Figure 1
Echocardiographic parasternal short axis (A) and apical 4-chamber (B) view, showing a large, lobulated mass (white arrow) within the right atrium. LA, left atrium; LV, left ventricle; RV, right ventricle; RVOT, right-ventricular outflow tract.
Figure 2
CT pulmonary angiogram showing thrombus (white and black arrows) as dark filling defects in the main right (R) and left (L) pulmonary arteries.

Despite this, the patient remained haemodynamically stable with unchanged oxygen saturations and an improvement in his breathing. The patient was loaded with warfarin. To date, no internal malignancy has been found to explain this thromboembolic event.

Learning points

  • [triangle] The patient may have suffered pulmonary embolic events for several months.
  • [triangle] Massive acute pulmonary emboli can be tolerated and be ‘silent’.
  • [triangle] Suspect pulmonary emboli in the breathless patient.
  • [triangle] Exclude an occult malignancy as a cause.


Competing interests None.

Patient consent Obtained.

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