Tödliche Pulmonalarterienembolie unter dem Bild der Anapylaxie

An 18-year old young woman was admitted to our emergency department by ambulance service. She complained of nausea and fainting after the peroral application of 1 tablet of diclofenac, which was taken for lower back pain that had persisted for three days. The clinical situation was attributed to an anaphylactic reaction due to diclofenac. As this diagnosis seemed plausible, the patient was treated with steroids, histamine blockers and fluids. After 4 days the patient completely recovered and laboratory values returned to normal. Two days later the patient had a cardiac arrest, which was attributed to massive pulmonary embolism. Despite maximal resuscitative effort the patient died. Assuming that the recurrent pulmonary embolism was the cause of death we have to ask, why the diagnosis of pulmonary embolism was not made earlier. During the first four days no anamnestic data, symptoms or clinical findings suggestive for pulmonary embolism occurred. However, structured anamnesis, routine ECG, and D-dimer determination were not performed in that clinically clear case of anaphylaxis". Maybe one of these measures would have raised suspicion for pulmonary embolism. This case indicates that structured anamnesis, routine ECG, and D-dimer determination should even be performed in emergency conditions and in situations, when diagnosis seems clinically plausible.