Endocrine Abstracts

Clinical practice suggests that low dose steroid treatment delivered locally to the site of action may rarely lead to disturbances of the hypothalamic-pituitary-adrenal axis. We present three clinical examples:Case 1: A 72 yr old man with a history of severe sinusitis was referred because of three episodes of profound anorexia, vomiting and proximal muscle weakness which coincided with discontinuing his Betnesol (betamethasone sodium phosphate 0.1%) nose...

The index patient is a 40 year old male with BPES (Blepharophimosis, Ptosis, Epicanthus inversus Syndrome) associated with isolatedgrowth hormone deficiency. BPES is a rare genetic disease occurring either sporadically or as an autosomal dominant disorder. There are two phenotypes; in type 1, eyelid abnormalities are associated with ovarian failure and in type 2 eyelid abnormalitiesonly. The genes for both types have been mapped ...

Wegeners granulomatosis involving the pituitary is rare, only a few cases having been reported. Most cases, diagnosed histologically or by response to treatment affect the posterior pituitary and occur in the presence of systemic vasculitis.A histological diagnosis of Wegeners granulomatosis was made in a 51 yr. old female in 1994 after presentation with upper respiratory tract symptoms and collapse of her nasal septum and bridge. At this time, gonadotr...

IntroductionHypercalcemia is a recognised feature of parathyroid and neoplastic disorders and similarly erythrocytosis is recognised in some benign and malignant neoplasm.Case reportA 71-year-old man presented to the admissions unit with an episode of collapse. No significant neurological or cardiovascular cause was identified. The results of his routine investigation revealed haemoglobin of 19.7g/dl and a ...

Type 1 Diabetes is typically a disease of the young but can present at any age. It is important to ensure correct categorisation as the acute complications related to insulin deficiency can occur and can be life threatening. It is important for physicians to maintain a high index of suspicion while dealing with newly diagnosed diabetes in an older patient. The following case report illustrates the fact that Type 1 Diabetes can present in the elderly.CAS...

Management of Thyrotoxicosis in a Non-compliant Pregnant WomanA 23-year-old woman with Grave's disease presented to thyroid clinic 29 weeks into her first pregnancy having recently moved into the area. She had failed to attend hospital thyroid clinics elsewhere and frequently changed her address.Despite propylthiouracil 300 mg daily she had marked tremor, tachycardia 100 bpm, ophthalmopathy, and a large smooth goitre. TSH <0.0...

The glucagon stimulation test (GST) is used as a provocative test of the hypothalamic pituitary adrenal axis (HPAA) but the response to this test is variable and the mechanism of action remains unclear. The GST has never been studied in diabetic patients with autonomic neuropathy (AN). We illustrate the assessment of cortisol response in two diabetic patients with AN who were suspected of having adrenocortical deficiency. Case one: A 40 year old type 1 diabetic suffers from di...

INTRODUCTION: Brittleness is a well-known phenomenon in patients with type 1 diabetes mellitus (DM). The possibility of a similar theme in the context of Addison's disease is not well established. CASE STUDY: We describe a 22-year-old woman who has had Addison's disease since the age of 9 years and type 1 DM since the age of 18 years. She was admitted with acute medical problems 47 times and attended OPD clinics on 17 occasions in 5 years (1996-2000). Of these, 29 inpatient an...

The most common cause of a mass lesion in the sella is pituitary adenoma. Some parasellar lesions may be cystic and sometimes may mimic the clinical and radiological features of pituitary adenoma. A 36 year-old woman was admitted to the hospital because of headache for five years and amenorrhoea for five months. Magnetic resonance (MR) imaging of the pituitary gland showed sellar mass lesion characterized by high signal intensity on T1 and T2-weighted images. Endocrinological ...

An eight-year-old girl developed Insulin Dependent Diabetes Mellitus. Two years previously, she had been referred to the Department of Endocrinology with concerns regarding short stature, but had not attended. She was mildly dysmorphic and her height and weight both plotted to below the 0.4th centile for age (Height Standard Deviation Score = -3.75, Weight Standard Deviation Score = -2.28). Her mother was also noted to be short at 147.2cm. There was no family history of deafne...

An 18-year old male presented with galactorrhoaea and obesity. PRL measured 16,630 mU/l, FSH 6.0 U/l, LH 5.0 U/l, testosterone 8.6 nmol/l, SHBG 15.0 nmol/l, IGF-1 22.0 nmol/l and TSH 1.39 mU/l. Several 24-hour urinary free cortisol estimations excluded hypercortisolism. Short synacthen test confirmed an intact HPA axis. Visual fields were full. Pituitary-MRI revealed a large adenoma extending into the right cavernous sinus without suprasellar extension. PRL started declining u...

Glucocorticoid remediable aldosteronism (GRA) was first described in 1966 by Sutherland et ala. In this family, aldosterone secretion was regulated by ACTH and symptoms and signs were reversed by the administration of exogenous glucocorticoid. GRA is usually characterised by moderate to severe hypertension with early onset. The hypertension is often difficult to control and is associated with greatly increased vascular risk. It is inherited as an autosomal dominant trait and ...

INTRODUCTION: Although thyrotoxicosis involving the musculoskeletal system is well described, classically presenting with proximal myopathy, arthralgia and osteopenia, an acute synovio-arthritis is extremely rare. There are only two published case reports, which have features distinct from Rheumatoid, Sjogren's and Psoriatic arthropathy.CASE REPORT: A 21-year-old lady presented with a 2-month history of symptoms and signs consistent with thyrotoxicosis....

A 24-year old male who, was normal at birth, became listless and volume depleted at 3 weeks of age. Investigations yielded an Addisonian picture (serum Na+ 115 mmol/l; K+ 8.2 mmol/l; urea 15.8 mmol/l). Serum 17-hydroxyprogesterone (17-OHP) levels were measured and found to be high (2,564 nmol/l). Urinary 17-oxosteroids and 17-OHP were also elevated. The neonate was thought to have 21-hydroxylase-deficient congenital adrenal hyperplasia (CAH) and therapy with fludrocortisone an...

A thirty year old woman with complete 21-hydroxylase deficiency presented with a five centimetre adrenal mass necessitating operative removal to exclude malignant change. Her medical management had always been unsatisfactory, and she had been tried on both hydrocortisone and dexamethasone. When taking 1 milligram dexamethasone daily she had partially suppressed androgen levels, (evidenced by a fall in 17-hydroxy-progesterone levels to 29 nmol/l), at the expense of marked Cushi...

A 22 year old female was referred for investigation of cramps in both hands, and tingling in her face. She also complained of lethargy and occasional dizziness. Routine testing by her General Practioner had demonstrated a low serum calcium. She had had problems at birth with hypocalcaemia. A diagnosis of hypothyroidism had been made previously, but she had stopped taking thyroxine medication. Both her mother and grandmother had required intermittent calcium supplementation. On...

A 67 yr old lady was admitted with left ventricular failure, angina, and atrial fibrillation. She was hypokalaemic (2.5mmol/l). There was a 3 year history of hypertension and a new diagnosis of diabetes mellitus. There was a recent history of weight gain, muscle weakness, bruising and facial puffiness. On examination she appeared cushingoid. A 24 hour urine for free cortisol was 1438nmol\/24h (normal<350). A basal 0800h serum cortisol was 1061nmol/l. After low dose dexameth...

Introduction. We present a rare and unusual case of direct trauma to the pituitary region.History. A 22 year old female, 8 weeks post-partum, fell downstairs on to a metallic clothes drier. A metal spike 3mm wide and approximately 20cm long penetrated her right eyebrow. Computed tomography showed a haemorrhagic track involving the hypothalamic region, and extending to the left internal capsule. Irritability and instability of vital signs necessitated in...

Case ReportA 36 year old Asian female presented to the Accident and Emergency with a sudden collapse.On examination, the patient was pyrexial at 38.3 degC and had a Glasgow Coma Scale of 4 associated with nuchal rigidity. The patient was ventilated and transferred to ITU. An MRI head scan revealed a large ring enhancing lesion in the hypothalamus which extended to the third ventricle. There was also diffuse lepto-meningeal enhancement with hydrocephalus....

Background & Methods: Occasional case reports of individual patients with scalp hairloss while receiving somatostatin analogues for acromegaly led us to audit similar patients in our departments.Results: Ten patients (four men, mean age at diagnosis 44.7years [range 26-65years]) who have received somatostatin analogues either initially as primary therapy (50%) or as post-surgical treatment (50%) for uncured acromegaly reported significant scalp hair...

A 53 year old man with ANCA-positive glomerulonephritis was referred with a 3-month history of hypercalcaemia. There was no significant family history and treatment consisted of Maxepa concentrated fish oils 5g/day for glomerulonephritis and lansoprazole plus Bisodol (proprietary indigestion preparation containing calcium, magnesium and sodium bicarbonate) for a hiatus hernia. Investigations revealed a corrected calcium concentration of 3.06 mmol/l, phosphate 1.27 mmol/l, crea...

A 56 year old female presents with the rare association of primary hyperaldosteronism with primary hyperparathyroidism and prolactinoma. The association of primary hyperaldosteronism and other endocrinopathies has only rarely been reported. There have been three case reports meeting diagnostic criteria for MEN 1 with aldosterone secreting adrenal adenomas. In all three the other endocrinopathies were pituitary adenomas and hyperparathyroidism.The case p...

We describe a case of chronic hypokalaemia secondary to Gitelman's syndrome. A 17 year female presented with a 1 year history of lethargy, muscle cramps and intermittent generalised abdominal pain. She took no regular medications and had no significant past medical history or family history. She was normotensive with a significant hypokalaemic, metabolic alkalosis. Sodium=135mmol/l, potassium=2.7mmol/l, creatinine=75micromol per litre, bicarbonate=36mmol/l. The hypokalaemia pe...

Acromegaly is a condition resulting from the action of excess growth hormone. We report the first case of acromegaly occurring in an individual as a result of growth hormone replacement therapy.Features of acromegaly developed in a forty-year old gentleman who was commenced on growth hormone replacement in 1993 following resection of a craniopharyngioma. Prior to commencing therapy, peak growth hormone response to insulin-induced hypoglycaemia was less ...

Efficacy and Safety of High Dose Testosterone Therapy in Partial Androgen InsensitivityS. Bandyopadhyay, W.A.Watson, C. M.Park, P. Abraham, S. Philip, S. Acharya , J.S. Bevan. Department of Endocrinology, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN.INTRODUCTION: There have been few reports of the efficacy and safety of high dose androgen therapy in men with partial androgen insensitivity (PAI). We report on the responses of a p...

Xanthoma Disseminatum: A rare cause of hypopituitarismS Ray and PE Belchetz; The General Infirmary at Leeds, Leeds, UK.Xanthoma disseminatum (XD) is a rare, benign, normo-lipaemic condition characterised by non- Langerhan's cell histiocytosis which usually effects male children or young adults. Patients develop nodular or infiltrating papules that are distributed along flexural areas and mucosal surfaces. Meningeal infiltration ca...

A 45-year-old lady presented with a 12-month history of blurred vision. Visual assessment revealed a bitemporal hemianopia and CT scan demonstrated a large pituitary tumour with lateral and suprasellar extension. A GTT showed her growth hormone was raised basally at 7.5 milliunits per litre and incompletely suppressed to 5.7 milliunits per litre confirming acromegaly. Transsphenoidal hypophysectomy was performed. Histology confirmed a somatoptroph adenoma. Post operatively she...

A 34-year-old woman, presented to her General Practitioner with hot flushes. Investigations showed her to have a normal LH, FSH, free T4 and TSH. Her prolactin was elevated at 1110 milliunits per litre (NR <350 ). She had a normal menarche age 14 and had regular 28 day menstrual cycles. Before the onset of the hot flushes she had started to take agnus castus, a herbal remedy said to help symptoms of premenstrual tension.Whilst she continued to take ...

The high survival rate for patients with differentiated thyroid carcinoma (DTC) declines markedly in those with bony metastases. We compare the management of two patients with large dominant pelvic metastases.Case 1 63 year old man with R hip pain. Investigation revealed a 10cm lesion in the R hemi pelvis and subsequent imaging and biopsy revealed a 9th rib lesion and metastatic follicular DTC. He underwent 131 I ablation of the normal thyroi...

A 20 year of man with cerebral palsy (spastic diplegia and mild learning difficulties) initially presented to the neurologists with a 4 month history of deterioration in mobility and new difficulties in speech, swallowing and incontinence of urine. New proximal muscle weakness, dyskinesia and ataxia were noted bilaterally in all limbs, Myoclonic jerks and absence seizures were also seen. His swallowing deteriorated to the point where 'PEG' feeding was necessary. Exhaustive neu...

Mediastinal location of a functional parathyroid adenoma is a rare but a well recognised entity and Tc-99M sestamibi scan is an established imaging technique for the succesful localization of such tissues with a sensitivity and specificity of more than 90%. Here we report an unusual case of primary hyperparathyroidism presenting with a 3-cm mediastinal mass with no evidence of abnormal uptake of the isotope and subsequent resolution of the mass on further imaging.<p class...

Turner's syndrome (TS) is the commonest sex chromosome abnormality in females. It is associated with impaired glucose tolerance and hepatic dysfunction. However a medline search for primary biliary cirrhosis (PBC) and TS shows only one previously reported case (Spanish literature).A 36 year old patient was referred to the diabetes center with poorly controlled type 2 diabetes on gliclazide 80 mgs daily (HbA1C 11.2%) and elevated alkaline phosphatase (AKP...

Introduction: Evaluation and management of thirst and polyuric syndromes can be challenging in endocrine practice.Case report: A 24-year old lady presented with weight loss, thirst, polyuria, vomiting and abdominal pain. She had acromegaly treated by transsphenoidal surgery 5 years ago. Medications included hydrocortisone, thyroxine (T4), the oral contraceptive pill as well as bromocriptine for postoperative acromegaly. Examination revealed postural hyp...

Introduction: Congenital adrenal hyperplasia (CAH) is characterised by impaired gluco and mineralocorticoid and excessive adrenal androgen secretion from the adrenal cortex. More than 90% of cases of CAH are caused by defects in the steroid 21-hydroxylase (CYP21) gene. We describe the association between salt-losing 21-hydroxylase deficiency and growth hormone deficiency.Patients and Methods: We reviewed 4 patients with salt-losing CAH (CYP21), who pres...

Introduction: Riedel's thyroiditis is a rare chronic inflammatory disease of the thyroid characterised by an invasive fibrotic process.Case report: A 48-year old lady with newly diagnosed profound hypothyroidism was started on thyroxine and referred due to a rapidly enlarging goitre. Examination revealed a hard fixed goitre in an euthyroid patient. Thyroglobulin (titre 1: 10,000) and thyroid peroxidase (titre 1: 100,000) antibodies were strongly positiv...

Patients with Cushing's disease are well known to develop easy bruising due to cortisol excess but are also predisposed to thrombembolism.We present four patients who developed thromboembolism during active Cushing's disease.Case 1- Four year history of hypertension, osteoporosis and central obesity. A DVT developed prior to referral. Initial urinary free cortisol(UFC)was 524nmol/24hrs. Inferior petrosal sinus sampling indicated ...

Thymic carcinoma is a rare but aggressive cause of ectopic ACTH secretion, with fewer than 100 reported cases.Hypokalaemic alkalosis was found in a 38 year old woman who presented with a 2-week history of leg swelling, fatigue and dyspnoea. She was not obviously Cushingoid.ACTH-dependent Cushing's Syndrome was confirmed biochemically: urinary free cortisol (UFC) >8500nmol/day and serum cortisol 4060nmol/l, (no suppression on 8...

The index case, a 26-year-old man, presented with a 15-month history of gynaecomastia. Investigations revealed a large left-sided adrenal mass that secreted oestrone and oestradiol, with suppression of FSH, LH and testosterone production. It was removed in 1991 with correction of the hormonal abnormalities and follow-up has shown no recurrence to date.In April 2001 the eighteen-month old daughter of the index case developed greasy skin, acne, pubic hair...

Large corticotroph adenomas are uncommon pituitary mass lesions, representing around 10% of cases of Cushing's disease, and are often found to be locally invasive. 'Silent' corticotrophinomas stain for ACTH, but do not secrete sufficient ACTH to cause Cushing's disease. We describe a patient with an unusual mass presentation of a pituitary adenoma in whom there was also a marked discrepancy between the clinical and laboratory findings in the assessment of suspected Cushing's d...

A 75-year-old female presented with 12kg weight loss and malaise, 18 months after a diagnosis of type 2 diabetes mellitus. Abdominal CT scanning demonstrated bilateral adrenal masses and her symptoms responded rapidly to empirical treatment with dexamethasone. CT guided biopsy demonstrated adrenal hyperplasia.Centripetal weight distribution and proximal myopathy were prominent, and serum cortisol failed to suppress following standard 48h low dose (662nm...

Vitamin D is commonly used in the treatment of hypoparathyroidism after thyroid surgery. It is well recognised that excess vitamin D therapy leads to hypercalcaemia, and that this effect may be prolonged, lasting upto several weeks with some vitamin D preparations. We describe a case of severe, life threatening hypercalcaemia from vitamin D therapy, in which the duration of action of vitamin D was exceptionally long. A 51 year old lady presented with acute, severe haemorrhagic...

Thyroid eye disease usually occurs in patients with graves'hyperthyroidism although 5-10% of patients are euthyroid or are hypothyroid with positve TSH receptor binding antibodies. We describe a patient with primary hypothyroidism for 14 years prior to the onset of severe thyroid eye disease.A 61 year old lady with thyroid opthalmopathy was seen in the eye clinic.Previous history included diet controlled diabetes and primary hypothyroidism, adequately r...

Presentation: A 66 year old woman, was admitted as an emergency with one week history of profound weakness ('had to crawl to the fridge to get milk for tea'), lethargy, productive cough and hypokalaemia (GP results: Na 141, K 1.5, bicarbonate 47 (23-28), Creatinine 54 (μmol/l). Her medication: Amlodipine 5 mg od, Bendrofluazide 2.5 mg od, Aspirin 75 mg.PMH: hypertension, moderate COPD and peripheral vascular disease. She smoked 20 cigarettes a day an...

We report the case of a 73-year-old Cypriot man with bilateral adrenal histoplasmosis. He had spent many years working in Southern Africa and had retired to Cyprus more than ten years ago. One year prior to diagnosis he underwent an elective cholecystectomy. Pre-operatively bilateral adrenal co-incidentalomas were noted on ultrasound and computed tomography (CT). Fine needle aspiration showed adipocytes within the gland and the patient had no further investigations at this tim...

Cranial diabetes mellitus is not usually associated with microprolactinomas. We report a 29 year old lady who presented 8 months after the birth of her only child with a 4 month history of polyurea and polydipsia. She had also noticed galactorrhoea and decreased libido although she had never breastfed the child and had not resumed normal menstrual function. The birth of her child was normal and uncomplicated although she admitted to being stressed recently since the baby was h...

Macroprolactin is a complex of prolactin with immunoglobulin appearing to have limited biological activity, partly due to failure of this high-molecular weight complex to cross capillary walls.Macroprolactinaemia is a common phenomenon, it is thus important to identify this condition in order to avoid unnecessary investigations and treatment. Although the presence of macroprolactin can be confirmed by gel filtration chromatography, this is time consumin...

We report a case of hungry bone syndrome occured as thyrotoxicosis treated in the patient of Graves disease.The patient was a 37 year-old woman resistant to antithyroid therapy. Radioactive iodine ablation was applied as 10 milicuri. After the serum levels of thyroid hormones decreased to the normal range spontaneous tetany occured.Serum ionised calcium was 4.18 miligram per decilitre(4.25-5.24) and serum phosphate was 2.3 miligram per decilitre(2.5-4.5...

A 76-year-old lady developed a tender thyroid swelling following a fall at home. One month later she was admitted with acute dyspnoea, and increased pain and swelling in her neck. She was found to be hyperthyroid on endocrine testing: free T4 (FT4) 24.8 (9-20) picomoles/litre, free T3 (FT3) 8.1 (3.5-6.5) picomoles/litre and thyrotropin (TSH) 0.2 (0.4-5.5) mIU/litre. She also had a raised erythrocyte sedimentation rate (ESR) at 54 mm/hr. She was commenced on hydrocortisone and ...

A previously well 54 year old man, with no atherosclerotic risk factors, presented with a 10 month history of claudication. Arteriography showed extensive distal aortic and iliac stenoses.At surgery, (Aortoiliac and femoral bypass) extensive thrombus was found in the distal aorta. Post operatively good distal flow was confirmed. He was discharged on Aspirin.Fourteen days later the patient was readmitted hypotensive, pyrexic, with ...

A 22-year-old lady presented with an acute abdomen and underwent appendicectomy for early appendicitis. Post-operatively she developed headache, dizziness and neck stiffness, and later impaired attention and perseveration. Clinical examination showed papilloedema, a left IVth nerve palsy and left sided cerebellar signs. A CT head scan showed evidence of subarachnoid haemorrhage (SAH) and subsequent MRI confirmed SAH with some meningeal enhancement, as well as intraparenchymal ...

A 73 year old man presented in 1995 with impotence and a bitemporal field loss. Endocrine testing revealed hyperprolactinaemia (2741 mU/L) and hypogonadotrophic hypogonadism. Pituitary imaging confirmed the presence of a macroadenoma with significant suprasellar extension. He underwent uncomplicated transsphenoidal surgery, which was successful in decompressing the optic chiasm. Histology revealed a pituitary adenoma that immunostained weakly for prolactin only. In 1998 routin...

WF a 52 year old female was referred to the Hammersmith Hospital in August 2001 for further investigation of her persistently elevated fasted gut hormones (GIH) [all previously assayed at the Hammersmith Hospital]. WF was initially diagnosed with irritable bowel syndrome 16 years ago. Following an exacerbation of her condition 9 years ago, fasting gut hormones were performed, which showed gross elevation of all peptides measured.The possibility of a neuroendocrine tumour was p...

Macroprolactin(mPRL)is a high molecular weight form of prolactin(PRL)most commonly due to formation of a complex with IgG.The PRL in mPRL remains reactive in immunoassays for PRL and the complex has a longer plasma half life than monomeric PRL.mPRL is a common cause of hyperprolactinaemia but its origin is not known and the complex has minimal bioactivity in vivo.The clinical significance of hyperprolactinaemia due to mPRL is that it can cause diagnostic confusion and lead to ...

In an attempt to audit one aspect of the endocrine nurse's workload, all incoming telephone calls to our office were monitored over a two month period.Details recorded were the call source, the query raised and the time taken by the nurse to respond appropriately. We went on to analyse the information gathered to ascertain areas where improved clinical practice could alleviate the need for further calls.Calls totalled 200 in the ...

We report the case of a 57-year-old woman who presented with headache of sudden onset and with blurring of vision in the right eye. This had been preceded by a week's history of fever, rigors and coryzal symptoms which had been treated as malaria and had subsequently settled. Examination demonstrated proptosis and complete ophthalmoplegia of the right eye with 6/60 acuity. Baseline investigations included normal urea and electrolytes, clotting screen and full blood count, with...

An 18 year old nursery nurse suffered two probable seizures. She was commenced on Phenytoin. She had had a cleft palate repair. Clinical examination revealed hypertelorism and short fourth metatarsals. Early papilloedema was noted. Routine blood tests showed profound hypocalcaemia of 1.2 mmol/l. Serum phosphate , magnesium and parathormone levels were normal. She suffered a further seizure and was given intravenous calcium. She suffered no further seizures and calcium levels w...

A 77 year old lady was referred by her GP after she was found to have a 6x5x5 cm diameter solid mass in the right adrenal gland on ultrasound scan. The mass showed significant internal vascularity on colour doppler and the radiologist felt it could be aphaeochromocytoma. She had a long history of hypertension which her GP had been finding difficult to control over the past 2 years.Type 2 diabetes was diagnosed 2 years ago and she...

We present the case of a thirty five year old salesman in whom microscopic haematuria was detected during a routine employment medical. History and physical examination were unremarkable. A renal ultrasound initiated by the urology service revealed an upper abdominal mass. CT abdomen confirmed a 5x6cm lesion distinct from the right kidney and adrenal gland. A CT-guided biopsy precipitated a hypotensive crisis (90/60mmHg) and hypoglycaemia (blood glucose 2.3mmol/l). 24-hr urina...

We present the case of a 31 year-old woman, para 2, who presented with a 2-year history of secondary amenorrhea. History and physical examination were otherwise unremarkable. Androgen and prolactin levels were normal. LH levels (10.3 U/L) and estrogen levels (280 pmol/l) were normal but FSH levels were repeatedly low ( < 1 U\/l). Growth hormone, free T4, TSH and cortisol levels were also normal. Pelvic ultrasound showed an enlarged right ovary (8 x 5 x 5 cms). Surgery, reve...

We report the case of a forty nine year old housewife who developed life-threatening acute adrenal failure. She was 3 weeks post-hysterectomy & had received prophylactic anticoagulation perioperatively. 2 weeks posthysterectomy she developed pleuritic chest pain. Low molecular weight heparin (LMWH) was started.V/Q lung scan proved negative for pulmonary embolism. A week later she represented in a hypotensive, hypoxic state with signs of infection and pulmonary embolism. CT...