Progressively worsening s...

A 40-year-old male without a family history admitted with progressively worsening shortness of breath two years ago. He had a H/o acute pulmonary embolism ten years ago, was treated with an anticoagulant and confessed to stopping anticoagulant therapy by himself six months ago. Physical examination revealed BP 100/60 mmHg, PR 110 beats/minute, RR 24 breaths/minute, jugular venous distention, and pitting oedema in both lower extremities. Blood tests revealed 6.04 µg/mL D-dimer, pro-BNP 6963 pg/mL, and platelet 97×109/L. His artery blood gas analysis (room air) revealed pH 7.47, PCO2 23 mmHg, PO2 67 mmHg, and O2 saturation 92. 

An electrocardiogram showed sinus tachycardia, right axis deviation, and right ventricle hypertrophy. In addition, a chest X-ray revealed right ventricle enlargement and bilateral pleural effusion. Continuous-wave Doppler signal showed an enlarged pulmonary artery with severe pulmonary hypertension, as shown in the figure. Chest computed tomography (CT) revealed eccentric filling defects in the central and main pulmonary arteries. In addition, a CT venogram showed diffuse thrombus from the suprarenal to the femoral vein.