Importance of history in the diagnosis of pulmonary embolismBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1692 (Published 19 March 2013) Cite this as: BMJ 2013;346:f1692
- Felix I D Konotey-Ahulu, Kwegyir Aggrey distinguished professor of human genetics, University of Cape Coast, Ghana, consultant physician genetic counsellor in sickle cell and other haemoglobinopathies1
Takach Lapner and Kearon’s clinical review omits an important cause of pulmonary embolism.1 Doctors should suspect sickle cell haemoglobin C disease whenever an African woman with normal haemoglobin concentration presents with unresolved pneumonia or severe breathlessness and should connect her illness with multiple pulmonary emboli.2 Hyperviscosity is a feature of the sickle cell phenotype and in my clinic in Ghana “of the 377 consecutive patients with sickle cell haemoglobin C disease, the mean haemoglobin concentration was 112 g/L; concentrations were above 135 g/L in 69 patients, and reached 165 g/L in two”.1 3 Because 1% of West Africans have the SS phenotype and 1% the SC phenotype, whether at home or abroad,4 it is important not to miss them in clinical practice.
The authors were right to mention not only “hypercoagulability” but also “tachypnoea” and “high clinical suspicion for pulmonary embolism,”1 yet doctors sometimes dismiss the importance of history, as one African mother’s experience shows.5 On accompanying her 32 year old breathless daughter to a London hospital where she worked as a nurse, she told doctors that her daughter had sickle haemoglobin C disease and had been on oral contraceptives. In spite of this vital history, the haematologist diagnosed “sickle cell crisis with chest syndrome,” and while the mother looked on her daughter was given an intravenous injection of diamorphine. She died promptly,5 and necropsy showed pulmonary embolism.
Cite this as: BMJ 2013;346:f1692
Competing interests: None declared.