Case 82 – update 1

Thanks for all the contributions! We now know from the history and investigations requested that:

This patient has had no obvious provoking factors for both his previous and current PE – including no symptoms/signs suggestive of autoimmune disorder / maligancy. He is compliant with his rivaroxiban, taking it appropriately with his main meal and is not on any other medications. He has no family history of thrombosis.

Investigations to date:

Hb 135, Plts 120, WCC 3.8, Neuts 1.9. U+Es, LFTs normal.

CT abdo / pelvis: no evidence of maligancy. Echo: NAD.

Paroxysmal nocturnal haemoglobinuria and antiphospholipid screen in progress (with understanding that lupus anticogulant may be false positive result as on anticoagulation).

Thrombophilia screen not performed as not going to change management and no family history with known disorder.

He was sent home on enoxaparin whilst being loaded on warfarin. However, he represents 3 days later feeling awful with increasing SOB and CTPA imaging confirms extension of his recent PE. He also has new renal and liver dysfunction.

What is your potential differential diagnosis and what additional investigations would you want at this stage?

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