QuestionQUESTION: My healthy, active 45-year old husband was admitted to the ER four weeks ago with stabbing back pain (especially when attempting to take deep breaths). D-dimer results called for a CT scan where 3 embolisms were discovered. Two were in the lower lobes of his lungs. He was treated with Heparin and started on Coumadin therapy and released three days later. He was only home one and a half days when lower quadrant back pain (excruciating) sent us back to the ER. Diagnosis was pleural effusion with subsegmental atelectasis. The fluid buildup was causing severe pain when breathing. A short course of Prednisone really eased his pain and after 3 days, he was again released. Care has been turned over to our family internist. My husband has seen the pulmonologist, who seemed to be pleased with his progress, and he has an appointment with a hematologist to check for possible genetic blood disorders (his lupus anticoagulant test which was done in the hospital was positive). Our question is this, however. My husband is still experiencing the "flank" pain which is worse when he tries to lay down. It's no longer excruciating, but on a scale of 1-10, it remains about a "3" and improves with Tylenol but comes back when it's time to take another dose of Tylenol. We've been told that recovery from these embolisms takes anywhere from one to six months. We understand that the clots will eventually be reabsorbed into the body, but how long will this pain continue? Is it normal? How long will areas around these clots leak fluid (causing the pain)? We are back to exercising, but very gradually, now up to about 3 to 4 miles per day. (He's a marathoner and avid cyclist, so it's been challenging for him to "gradually" get back to his workouts, but he really IS following doctor's orders, and taking it slow.) The fear is consuming and constant, as we're learning about the Coumadin "level" and dietary guidelines, and learning about ways to help prevent another embolism. But right now our greatest concern is the lower back "flank" pain. How much is "normal" healing, and at what point should we consider going back to the emergency room? Thank you so much for any suggestions you may have, and for sharing your time and expertise.
Sincerely, Karen and Steve
ANSWER: If the flank pain is from the effusion and pulm embol, it should resolve over the next week or two... but, I always look for other causes too... kidney stones? and, you are over simplifying the fluid and pain... the clots don't really leak fluid. He probably developed pleuritis (inflammation of the lining of the lung) from the clots and this slowly resolves with time, much faster with the prednisone. This is a complicated issue and the fluid/pain has to be followed and re-evaluated closely...
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QUESTION: Dr., Just a couple other questions, please. Most of the cases we've read about pulmonary embolism indicate the patients experienced chest pain, but not many presented specifically with back pain. (Steve's pain was ONLY in his back.) Is this unusual? If there's no genetic blood clotting disorder (which we will find out later this week), is he still more prone to embolisms in the future? Could this be an "isolated" event? Our physician said Steve would probably be on Coumadin for at least a year and sometimes for life. Once some people are off the Coumadin, (which would be scary), are the probabilities for another pulmonary embolism greater (once you've had one)?
Tests indicated that he did not have a DVT, we hadn't had a long plane ride, but we drove home from Cincinnati a month prior to his embolism. We got out of the car two or three times on the drive home - the last "leg" of the trip being about 4 and 1/2 hours. (As I mentioned, Steve is a seasoned athlete and this ride home was a day and a half after he ran the marathon in Cincinnati. We stayed the extra day to walk around Cincinnati to enjoy the town and so he could recover from the race - as we usually do - and avoid sitting in a car so soon after a body-taxing event.) We thought we were doing everything "right", but after thoroughly going over & over when this could have happened, the Cincinnati race seemed the likeliest "culprit". On the other hand, doctors have told us that it quite possibly was the terrific shape Steve's lungs are in that may have saved his life. Also, because of his fitness level, his resting heart rate was quite low - about 45 BPM before this embolism. He's also been on blood-pressure medication for years and it's been well-controlled.
Forgive my "going into detail" about possibilities leading up to this event, but as I mentioned in my first correspondence to you, this has been a completely scary "out-of-the-blue" medical event for us, and we're really still in shock, but feel extremely blessed, as many aren't so fortunate.
My questions to you are really only in the first paragraph, Dr. Borucki. Again, thank you for your expertise and especially your patience.
Sincerely, Karen & Steve
AnswerI can't give you the reassurance you want over the internet.... what caused it? often we simply don't know. you listed the risks... airplane rides, high altitudes, sitting in tight quarters for long periods of time... but often we can't pinpoint it. If I were him, I would stay on Coumadin for a long time and wonder about having a vena cava filter placed. Pulm embolism remains one of the more difficult diseases to diagnose because it presents so differently in each person.
