Acta med. scand. Vol. 197, pp. 431-432, 1975

TOTAL DISAPPEARANCE O F A FATAL PULMONARY EMBOLUS DURING STREPTOKINASE THERAPY O F AN ILIOFEMORAL THROMBOSIS

Jan Eklund, Evald Johansson and Christer Paul

From the Departments of Anaesthesia and Surgery and the Coagulation Laboratory, Karolinska Hospital, Stockholm, Sweden

Abstract. During streptokinase treatment of an iliofemoral thrombosis, a formerly healthy man developed clinical signs of major pulmonary embolism. In spite of all at- tempts at resuscitation, the patient died after 1.5 hours. The autopsy showed no signs of remaining thrombus or emboli. The probable explanation is that the thrombus had partially been lysed and that the remaining parts formed an embolus large enough to cause considerable haemo- dynamic changes which could not be influenced. Lysis continued pre- and postmortally and was complete at the time of autopsy.

For many years the relationships between clini- cal and pathological findings have been well established. Most often the findings at autopsy can be predicted and sometimes the clinical picture is so characteristic that an autopsy seems almost un- necessary. However, therapy changes and it should not be forgotten that the introduction of new methods may completely change a morphological picture familiar to a pathologist. Having met with such a situation in the unsuccessful treatment of a man with a deep venous thrombosis who died from a classical pulmonary embolism, we found it of particular interest to report the features of this case.

CASE REPORT A formerly healthy and quite alert 77-year-old man was hospitalized because of pain and swelling of the right leg for two days. The obvious clinical diagnosis was an iliofemoral thrombosis. Ascending phlebography showed an almost total occlusion of the veins up to the inferior vena cava. Apart from a peripheral thrombocyte count of 56000 and a bleeding time of 12 min there were no abnormalities on laboratory examination at this time. Ac- tive thrornbolytic treatment was started by a constant infusion of streptokinase (Kabikinas", Kabi, Stockholm, Sweden). No initial dose titration was performed; instead the patient received 300000 IU streptokinase during one

hour, after which the treatment continued with 100OOO IU/hour.

Four hours after treatment started the thrombin time was more than double the normal, indicating a fibnnolytic effect. After 15 hours' treatment the patient was definitely improved. He had no pain and only moderate swelling of the leg remained. No complications to the thrombolytic therapy had been observed. Two hours later the patient suddenly deteriorated with all the classical signs of a ma- jor pulmonary embolism, including circulatory collapse.

The patient was immediately treated with oxygen and assisted ventilation and was rapidly transferred to the Intensive Care Unit. Further he received papaverine (80 mg), merperidine (50 mg), theophyllamine (200 mg) i.v. and isoprenaline (1 mg) in 500 ml of a 5.5% dextrose solution. Nevertheless he did not improve and because of cyanosis he was intubated and ventilated with pure ox- ygen and a positive endexpiratory pressure of 10 cm H20 by means of an Engstrom ventilator 300 (LKB-medical,, Stockholm, Sweden) without any evident improvement.

During this treatment the ECG showed gradually in- creasing signs of myocardial hypoxia, but no arrhythmia was observed. The systolic BP vaned between 50 and 80 mmHg. After one hour's treatment the circulation failed completely, though the ECG showed a fairly regular rhythm. No pulses could be felt and the pupils became dilated. External cardiac compression was without effect and at no time could any sufficient circulation be obtained. The resuscitation was stopped after 1.5 hours.

Four hours after death the body was transferred to a cold room and the autopsy was performed % hours later. At this time neither a pulmonary embolus nor a deep venous thrombus could be found. The heart was dilated but not hypertrophic and there were signs of venous con- gestion in both lungs and the liver. No signs of myocardial infarction could be found. Multiple bleeding was observed in the pancreas.

DISCUSSION

As there had been no doubt about the clinical diagnosis of major pulmonary embolism, the post mortem findings came as a complete surprise.

Acta med. scand. 197

432 J . Eklund et al.

However, on further consideration we have ac- cepted the following explanation.

Before the treatment started the patient had a thrombosis engaging the main veins of the entire right leg. As he improved markedly, it must be assumed that most of the thrombus had been dis- solved. However, enough material was left to con- stitute a considerable embolus, which unfortunately was lethal, even though it was under continuous dissolution. If the embolus had not totally disin- tegrated at the time of death, it is quite possible that lysis continued during the first hours afterwards. Consequently no solid material was found at au- topsy. The tragic fact that the patient succumbed in spite of successful thrombolysis was probably due to the persisting haemodynamic changes, signs of which were to be seen at autopsy. These changes, together with hypoxia and-most certainly-a con- siderable stress, were evidently too great a strain for this fairly old man.

The hypothesis of a continuous and finally total lysis of a lethal embolus is supported by the findings of Gajewski (1). In his report of a lethal case of

pulmonary embolus during thrombolytic therapy he described the embolic material as gelatinous, half liquid and thus partially lysed.

As active fibrinolytic therapy is being used more and more in patients with thromboembolic disease (2, 3, 4 , S), we find it important to point out this possible change in a formerly distinct pathology.

REFERENCES 1.

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GJewski, J.: Thrombolytic therapy and fatal massive pulmonary emboli. Ann. intern. Med. 74:450, 1971. Kakkar, V. V., Flanc, C., O’Shea, M. J., Flute, P. T., Howe, C. T. & Clarke, M. B.: Treatment of deep-vein thrombosis with streptokinase. Brit. J . Surg. 56: 178, 1969. Mavor, G. E., Dhall, D. P., Dawson, A., Duthie, J . S . & Walker, M. G.: Streptokinase in deep vein thrombosis. Brit. J. Surg. 60: 468, 1973. Robertson, B. R.: On thrombosis, thrombolysis and fibrinolysis. Acta chir. scand., Suppl. 421, 1971. Tsapogas, M. J., Peabody, R. A., Wu, K. T., Karmody, A. M., Devard, K. T. & Eckert, C.: Con- trolled study of thrombolytic therapy in deep vein thrombosis. Surgery 74: 973, 1973.

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