When Clots and Bleeding Collide: A Case of Bilateral Pulmonary Embolism With Hemoptysis and Pleural Effusion

Abstract Background: Pulmonary embolism (PE) is a life-threatening condition that can be complicated by bleeding, pleural effusion, and other comorbidities, making diagnosis and management challenging. This case report highlights the diagnostic difficulties and management of bilateral PE complicated by hemoptysis, pleural effusion, and anticoagulation therapy in a high-risk patient. Case Description: A 56-year-old female with hypothyroidism presented with progressive shortness of breath, productive cough, and pleuritic chest pain, symptoms that had worsened over the past two days, though present for four months. On examination, she appeared stable with normal vital signs. Laboratory tests revealed mild hyponatremia and an elevated white blood cell count, with cardiac biomarkers (troponin and BNP) mildly elevated, suggesting right heart strain. Chest X-ray showed left lower lobe pneumonia, and CTA confirmed bilateral PE in the right lower lobe and left lingula. A Doppler ultrasound detected deep vein thrombosis (DVT) in the right leg, likely the source of the emboli. She was initiated on heparin anticoagulation and empiric antibiotics (ceftriaxone and azithromycin). Despite initial improvement, her hemoglobin levels fluctuated, dropping from 12.3 g/dL to 8.5 g/dL, raising concern for gastrointestinal bleeding. An esophagogastroduodenoscopy (EGD) was performed, which ruled out GI bleeding. Repeat imaging revealed a large pleural effusion. Thoracentesis drained over 1 liter of blood-tinged fluid, and a pigtail catheter was inserted for continued drainage. An IVC filter was also placed. Despite that, her clinical status worsened, with right heart strain noted on point-of-care ultrasound. Her oxygen needs increased, prompting consideration for catheter-directed thrombolysis (CDT). Following CDT, her oxygenation improved, and her clinical condition stabilized. She was transitioned to Lovenox after chest tube removal and discharged in stable condition. Discussion and Conclusion: This case highlights the complexities of diagnosing and managing PE, particularly when complicated by pleural effusion, fluctuating hemoglobin levels, and anticoagulation therapy. The initial suspicion of gastrointestinal bleeding was ruled out through EGD, but pleural effusion was identified as the source of blood loss on subsequent imaging. Early reassessment through repeat imaging was crucial to identifying this complication. Catheter-directed thrombolysis (CDT) was effective in this high-risk patient with right heart strain, providing targeted thrombolysis with reduced systemic bleeding risk. CDT offers a promising alternative to systemic thrombolysis in submassive PE, especially in patients who are at increased bleeding risk. This case emphasizes the importance of early imaging reassessment and targeted thrombolysis in complicated PE cases.