Pulmonary embolism in pediatric age: A retrospective study from a tertiary center

Abstract

Introduction: Pediatric pulmonary embolism (PE) is rare but associated with adverse outcomes. We aimed to characterize PE cases admitted in a tertiary hospital and to evaluate sensitivity of selected PE diagnostic prediction tools.Methods: Retrospective, descriptive study of PE cases admitted from 2008 to 2020 using data collected from hospital records. Patients were grouped according to PE severity and setting (outpatients vs. inpatients). Links and correlation with demographic characteristics, risk factors, clinical presentation, management, and outcomes were analyzed. PE diagnostic prediction tools were applied.Results: Twenty-nine PE episodes occurred in 27 patients, 62.9% female, mean age 14.1 years. Most PE were central and split between massive or submassive. One was diagnosed in autopsy. Twenty outpatients, all adolescents, were admitted for classic PE symptoms; in half of them the diagnosis had been previously missed. Risk factors included contraceptives (65%), thrombophilia (35%), obesity (20%) and autoimmunity (20%). Eight inpatients, diagnosed during cardiorespiratory deterioration (n = 5), or through incidental radiological findings (n = 3), were younger and had immobilization (87.5%), complex chronic diseases (75%), infections (75%) and central venous catheter (62.5%) as risk factors. Retrospectively, D-dimer testing and adult scores performed better than pediatric scores (sensitivity 92.9%-96% vs. 85.7%-92.9%). Both pediatric scores missed a case with a positive family history.Discussion: Pediatric PE diagnosis is often delayed or missed. Development of pediatric prediction tools from validated adult scores merits being explored. We argue clinical presentation and risk factors may be different in inpatients and outpatients and propose broader reliance on family history.

The Neglected Fact

“…In children, the diagnosis of PE may be missed or delayed, mainly because of the rarity of the disease. It is noteworthy that in the previous literature, the lag between clinical manifestations and diagnosis was shown to be approximately 0 to 42 days, while in another study in children, the lag time was 1 to 16 days 1,2 . Computed tomography pulmonary angiography is the preferred diagnostic modality, while ventilation perfusion scans and routine pulmonary angiography are used less frequently 10,15 .…”

“…Previous literature has described the efficacy and safety of low molecular weight heparin in children with nonseptic PE for 2 to 12 months. In a small number of cases, particularly in patients with right ventricular dysfunction and/or hemodynamic instability, the use of tissue plasminogen activator thrombolysis, thrombosis, or extracorporeal membrane oxygenation support is first considered 1,2 …”

“…Depending on the severity of the clinical presentation, pulmonary embolism is classified as (1) high risk (significant impairment of the cardiovascular system with significant hemodynamic changes), (2) moderate risk (right ventricular injury and/ or elevated troponin I or B type natriuretic peptide, no systemic hemodynamic changes), and (3) low risk. [1][2][3] In pulmonary embolism caused by septic infection, embolism originates from infectious microcirculation lesions such as endovascular catheterization, endocarditis, osteomyelitis and septic arthritis, liver and kidney abscesses, skin and soft tissue infections, and periodontal abscesses. 4 Pulmonary embolism is considered a rare disease in children and is often overlooked.…”

“…It is noteworthy that in the previous literature, the lag between clinical manifestations and diagnosis was shown to be approximately 0 to 42 days, while in another study in children, the lag time was 1 to 16 days. 1,2 Computed tomography pulmonary angiography is the preferred diagnostic modality, while ventilation perfusion scans and routine pulmonary angiography are used less frequently. 10,15 Ddimer levels are significantly elevated in approximately 80% of PE children, and electrocardiogram (ECG) shows changes in sinus tachycardia, T-wave inversion, and right bundle branch block.…”

“…In a small number of cases, particularly in patients with right ventricular dysfunction and/or hemodynamic instability, the use of tissue plasminogen activator thrombolysis, thrombosis, or extracorporeal membrane oxygenation support is first considered. 1,2 In a cohort study in Canada, 35% of children with large or sublarge area PE had adverse outcomes with 13% of children with nonlarge area PE, more specifically the progression or recurrence of PE, chronic thromboembolic pulmonary hypertension, and major bleeding associated with thrombolysis or PE. 10 In existing cohort studies, the high risk of death in patients with large areas of PE has been demonstrated.…”