Intended for healthcare professionals

Endgames Case report

Breathless beyond obvious

BMJ 2008; 337 doi: (Published 17 September 2008) Cite this as: BMJ 2008;337:a1405

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  1. Chloe Bloom, registrar
  1. 1Lewisham Hosptial
  1. chloebloom{at}

    A 56 year old woman with endometrial leiomyosarcoma and metastatic involvement of her lungs presented with a three day history of acute breathlessness from a background of intermittent breathlessness. Two months previously she had started chemotherapy with gemcitabine and docetaxel, and three days before admission she had completed her third cycle. A computed tomography scan done two weeks earlier showed minimal change in the bulk of the cancer, but a filling defect in her iliac vein was seen. Thrombosis was suspected, and anticoagulation treatment was started.

    The woman denied any cough, haemoptysis, fevers, or pain. On examination she had normal bilateral breath sounds, a respiratory rate of 35 breaths per minute, oxygen saturation of 87% on 15 l/min oxygen, a temperature of 38°C, heart rate sinus 120 beats per minute, blood pressure of 90/60 mm Hg, and normal heart sounds. The only abnormality on her chest radiograph was pulmonary metastases.

    Her respiratory and haemodynamic compromise was thought to be caused by a pulmonary embolism, and she was given 250 ml of intravenous colloid. This increased her tachypnoea, and new bilateral wheeze was heard on auscultation. A computed tomography pulmonary angiogram was performed and showed a filling defect in her right ventricle, diffuse bilateral pulmonary infiltrates, but no filling defects in her pulmonary vessels.


    • 1 What is the differential diagnosis of her breathlessness?

    • 2 How would you treat her breathlessness once the diagnosis is established?

    • 3 What is the differential diagnosis of the filling defect in her right ventricle?


    Short Answers

    • 1 Thromboembolic disease, …

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