Unusual Presentation of Pulmonary Embolism as Diaphragmatic Hernia - Case Study

Mohamed Saleh ^1*

This study shows the importance of comprehensive differential diagnosis in acute dyspnea with atypical findings to prevent misdiagnosis and improve outcomes.

Abstract

Pulmonary embolism (PE) is a critical condition characterized by thrombi obstructing pulmonary arteries, commonly originating from deep vein thrombosis. Typical symptoms include sudden-onset dyspnea, chest pain, and hypoxemia, although atypical presentations complicate diagnosis. Diaphragmatic hernias, involving abdominal organs displacing into the thoracic cavity, present with respiratory distress and gastrointestinal symptoms. The coexistence of PE and diaphragmatic hernia is rare, posing significant diagnostic challenges. This case report details a 65-year-old female with acute dyspnea and cyanosis following chest trauma, initially misdiagnosed with diaphragmatic hernia. Elevated D-dimer levels and clinical signs suggested PE, but CT pulmonary angiography revealed a large diaphragmatic hernia compressing the pulmonary arteries, causing pulmonary hypertension. This case underscores the importance of comprehensive differential diagnosis and advanced imaging to accurately identify overlapping conditions. It is important to consider differential diagnoses in acute dyspnea cases with atypical findings. Maintaining a broad differential diagnosis and a multidisciplinary approach is crucial to avoid misdiagnosis and ensure timely, appropriate treatment, thereby optimizing patient outcomes.

Keywords: Pulmonary embolism, Diaphragmatic hernia, Acute dyspnea, Differential diagnosis, Pulmonary hypertension

References

Adil, M., Tinley, P., & Scharf, J. (2002). Pulmonary embolism following repair of traumatic diaphragmatic rupture. American Surgeon, 68(1), 49-51. PMID: 11842958

Akamine, S., Tanaka, T., Oishi, H., et al. (2019). Pulmonary embolism associated with traumatic diaphragmatic hernia: A case report. International Journal of Surgery Case Reports, 63, 18-21. https://doi.org/10.1016/j.ijscr.2019.07.029

Al-Salem, A. H. (2013). Congenital diaphragmatic hernia: Current status and review of the literature. Frontiers in Pediatrics, 1, Article 43. https://doi.org/10.3389/fped.2013.00043

Ananthakrishnan, N., Parithivel, V., Gnanasekaran, S., et al. (2017). Incidental finding of traumatic diaphragmatic hernia leading to the diagnosis of massive pulmonary embolism. Annals of the Royal College of Surgeons of England, 99(8), e233-e235. https://doi.org/10.1308/rcsann.2017.0172

Athanassiadi, K., Kalavrouziotis, G., & Athanassiou, M. (1999). Adult Bochdalek hernia: Diagnostic and therapeutic challenges. Journal of Cardiothoracic Surgery, 14(3), 20-22. https://doi.org/10.1016/S1010-7940(98)00303-0.

Bakhos, C. T., Pupovac, S. S., Ata, A., et al. (2009). Diaphragmatic rupture presenting 50 years after the causative event. Canadian Journal of Surgery, 52(6), E251-E252. PMID: 20011145

Boni, L., David, G., Mangano, A., Dionigi, G., Rausei, S., Spampatti, S., Cassinotti, E., Fingerhut, A., & Dionigi, R. (2009). Clinical laparoscopy: An evaluation of its role in current surgical practice. Surgical Endoscopy, 23(2), 244-245. https://doi.org/10.1007/s00464-008-0054-5

Calvo, F., García-Sanz, I., Ochoa, A., et al. (2004). Traumatic diaphragmatic hernia with late onset of intestinal incarceration: Report of a case and review of the literature. Hernia, 8(2), 177-179. https://doi.org/10.1007/s10029-003-0180-8.

Chughtai, T., Ali, S., & Sharkey, P. (2012). Late presentation of traumatic diaphragmatic rupture. International Journal of Surgery Case Reports, 3(5), 147-149. https://doi.org/10.1016/j.ijscr.2012.01.011

Eren, S., & Ciris, F. (2005). Diaphragmatic hernia: Diagnostic approaches with review of the literature. European Journal of Radiology, 54(3), 448-459. https://doi.org/10.1016/j.ejrad.2004.09.004

George, E., Kourtesis, I., Velmahos, G., et al. (2003). Pulmonary embolism after traumatic diaphragmatic rupture: A rare but fatal complication. American Surgeon, 69(2), 164-166. PMID: 12641377

Killeen, K. L. (2020). Diaphragmatic hernia repair. In M. P. Osborne (Ed.), StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470443/

Konstantinides, S. V., Torbicki, A., Agnelli, G., Danchin, N., Fitzmaurice, D., Galiè, N., Gibbs, J. S., Huisman, M. V., Humbert, M., Kucher, N., Lang, I., Lankeit, M., Lekakis, J., Maack, C., Mayer, E., Meneveau, N., Perrier, A., Pruszczyk, P., Rasmussen, L. H., Schindler, T. H., … Zamorano, J. L. (2014). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. European Heart Journal, 35(43), 3033-3069. https://doi.org/10.1093/eurheartj/ehu283

Kozan, R., Taskesen, F., Yildirim, O., et al. (2014). Diaphragmatic rupture with concomitant pulmonary embolism: A case report. Case Reports in Surgery, 2014, Article 691086. https://doi.org/10.1155/2014/691086

Kulvatunyou, N., Vijayasekaran, A., Hansen, A., et al. (2014). Traumatic diaphragmatic injury: Is management with chest tube insertion alone sufficient? American Journal of Surgery, 207(1), 128-132. https://doi.org/10.1016/j.amjsurg.2013.05.005

Lee, W. C., Huang, J. H., Wu, M. J., et al. (2007). Acute respiratory failure due to pulmonary embolism in a patient with a traumatic diaphragmatic hernia: A case report. Journal of Trauma, 62(2), 515-517. https://doi.org/10.1097/01.ta.0000229987.12885.e4

 Lee, Y. C., Oh, S. J., Park, E. J., et al. (2019). Delayed presentation of a diaphragmatic rupture with acute massive pulmonary embolism: A case report. Medicine (Baltimore), 98(36), e16926. https://doi.org/10.1097/MD.0000000000016926

Moore, A. J., Thameur, H., Hartland, B. L., et al. (2004). Diaphragmatic rupture and pulmonary embolism after blunt trauma: A case report and literature review. Emergency Medicine Journal, 21(6), 747-748. https://doi.org/10.1136/emj.2003.011908

Morell, C. M., & Ross, S. E. (2013). An unusual case of traumatic diaphragmatic hernia presenting with pulmonary embolism. American Journal of Emergency Medicine, 31(1), 267.e5-6. https://doi.org/10.1016/j.ajem.2012.07.028

Morishita, K., Nishi, H., Inoue, T., et al. (2003). Delayed massive pulmonary embolism caused by traumatic diaphragmatic hernia. Annals of Thoracic and Cardiovascular Surgery, 9(1), 65-67. PMID: 12761803

Patil, H. R., Nakao, A., Tanaka, N., et al. (2013). Acute massive pulmonary embolism presenting as gastric perforation due to diaphragmatic hernia: A case report. Annals of Thoracic and Cardiovascular Surgery, 19(3), 224-227. https://doi.org/10.5761/atcs.cr.12.01704

Petrella, F., & Spaggiari, L. (1996). Pulmonary embolism after diaphragmatic hernia repair. Annals of Thoracic Surgery, 62(5), 1517-1518. https://doi.org/10.1016/s0003-4975(96)00740-5

 Salemis, N. S. (2011). Blunt diaphragmatic rupture presenting with extensive deep vein thrombosis and pulmonary embolism: A case report. Journal of Medical Case Reports, 5, 512. https://doi.org/10.1186/1752-1947-5-512

Shah, R., Sabanathan, S., Mearns, A. J., & Choudhury, A. K. (2016). Traumatic diaphragmatic injury. Postgraduate Medical Journal, 92(1085), 89-95. https://doi.org/10.1136/postgradmedj-2015-133638

Stein, P. D., Hull, R. D., Patel, K. C., Olson, R. E., Ghali, W. A., Brant, R., Biel, R. K., Bharadia, V., & Kalra, N. K. (2007). D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: A systematic review. Annals of Internal Medicine, 140(8), 589-602. https://doi.org/10.7326/0003-4819-140-8-200404200-00009

Torbicki, A., Perrier, A., Konstantinides, S., Agnelli, G., Galiè, N., Pruszczyk, P., Bengel, F., & Brady, A. J. (2008). Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). European Heart Journal, 29(18), 2276-2315. https://doi.org/10.1093/eurheartj/ehn310

Tyczynski, P., Zukowski, M., Kolodziejczyk, P., et al. (2015). Rare case of double simultaneous complication: Diaphragmatic hernia and pulmonary embolism after blunt chest trauma. Kardiochirurgia I Torakochirurgia Polska, 12(4), 390-392. https://doi.org/10.5114/kitp.2015.55900

Ward, J., Allen, R. L., Ecker, R. R., et al. (1987). Blunt diaphragmatic rupture: A potentially overlooked injury in victims of motor vehicle accidents. American Surgeon, 53(4), 205-209. PMID: 3562341

Wells, P. S., Ginsberg, J. S., Anderson, D. R., Kearon, C., Gent, M., Turpie, A. G., Bormanis, J., Weitz, J., Chamberlain, M., Bowie, D., Barnes, D., Hirsh, J., & Geerts, W. (2000). Use of a clinical model for safe management of patients with suspected pulmonary embolism. Annals of Internal Medicine, 132(2), 96-104. https://doi.org/10.7326/0003-4819-132-2-200001180-00004

Zaher, R., Al-Malki, T. A., & Hasan, M. (2008). Unusual presentation of traumatic diaphragmatic hernia: A review of 15 cases. Annals of Thoracic Medicine, 3(2), 54-57. https://doi.org/10.4103/1817-1737.39633