Bilateral pulmonary embolism while receiving tranexamic acid
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Pulmonary embolism (PE) is a common medical condition and remains life-threatening despite advances in its diagnosis and treatment past few decades. The incidence of PE is estimated to be approximately 60 to 70 per 100,000 in the general population. However, the true incidence is far more than what is reported, because PE remains one of the most commonly under-diagnosed medical problems.

A 46-year-old woman who was usually fit and well with no remarkable past medical history except for menorrhagia of 1-year duration for which she was receiving tranexamic acid presented to our accident and emergency department with a 2-week history of intermittent pleuritic central chest pain. She was reviewed and discharged to home with a diagnosis of musculoskeletal pain on two hospital visits because she had no significant risk factors for thromboembolism and her workup investigation results for pulmonary embolism and other differential diagnoses were largely unremarkable. On her third visit to the emergency ambulatory clinic with recurring symptoms of pleuritic chest pain, a pulmonary computed tomographic angiogram confirmed bilateral subsegmental pulmonary embolism.

Following the confirmation of PE diagnosis on the basis of imaging, our patient’s treatment dose of enoxaparin was changed to apixaban. The planned duration of treatment with apixaban was 3 months; however, this is usually subject to evaluation during patient follow-up in the anticoagulation clinic. Our patient was then advised to stop TXA and informed to use other painkillers, such as paracetamol and/or codeine phosphate, for pain control instead of mefenamic acid due to increased risk of bleeding caused by drug-drug interactions with apixaban.

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