Education And Debate

Grand Rounds--Hammersmith Hospital: Thromboembolic occlusion of a pulmonary arteriovenous malformation

BMJ 1995; 311 doi: (Published 26 August 1995) Cite this as: BMJ 1995;311:553
  1. Ian Sabroe
  1. Department of Medicine, Hammersmith Hospital, London W12 0NN

    Case presented by: Ian Sabroe, registrar in respiratory medicine. Chairman: S Bloom, professor of endocrinology. Discussion group: J M B Hughes, professor of respiratory medicine S Shaunak, senior lecturer in infectious diseases I Robertson, senior registrar in radiology. Series edited by: Dr W A Lynn.

    Pulmonary embolism is a common medical emergency, typically associated with hypoxia secondary to a ventilation perfusion mismatch. Pulmonary arteriovenous malformations are rare and cause hypoxia due to direct arterial venous shunting. We present the case of a woman with both pulmonary embolism and a pulmonary arteriovenous malformation in whom an embolus fortuitously occluded the malformation leading to a paradoxical improvement in oxygenation.

    Case history

    A 74 year old woman was admitted to her local hospital with a history of rapidly worsening shortness of breath over the preceding few weeks. She had been suffering from slowly progressive dyspnoea for one to two years, and over the past six months her friends had noticed that her lips and fingers were bluish. Recently she had also become short of breath at rest. She had smoked 40 cigarettes a day for 55-60 years, and chronic bronchitis had been diagnosed several years before. Five years ago, after a minor episode of haemoptysis, plain chest radiography had shown a probable pulmonary arteriovenous malformation. She refused further investigation or treatment of this. She had no history of nose bleeds or overt gastrointestinal bleeding and no neurological symptoms.

    On admission to her local hospital she was hypoxaemic and mildly hypercapnic on air (arterial oxygen pressure 6.6 kPa and alveolar carbon dioxide pressure 6.1 kPa). The hypoxaemia was unresponsive to oxygen therapy, suggesting the presence of a right to left shunt. Chest radiography again confirmed the presence of a possible pulmonary arteriovenous malformation. Four weeks after admission she was transferred to this hospital.

    On admission she …

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