Working Diagnosis:
Acute unprovoked bilateral pulmonary artery emboli with right lower extremity popliteal deep vein thrombosis

Treatment:
At the emergency department, the patient was started on supplemental oxygen, therapeutic lovenox, and apixaban 10 mg twice daily for one week then switched to apixaban 5 mg twice daily for at least three months. He was seen by inpatient Hematology-Oncology who ordered a hypercoagulable workup, hemoglobin electrophoresis, an antiphospholipid syndrome panel, and a comprehensive genetic evaluation for clotting disorders. During outpatient Hematology-Oncology follow-up he was recommended to continue taking apixaban 5 mg twice daily for a total of six months.

Outcome:
His symptoms resolved. An echocardiogram completed after about five months of anticoagulation was normal. A D-dimer completed after six months of anticoagulation and one month after stopping anticoagulation was normal. Hematology-Oncology estimated that the risk of a recurrent venous thromboembolism off anticoagulation in the next year was three to five percent.


At the time of diagnosis, he was started on anticoagulation treatment and held out of football due to the concern for a risk of head injury and bleeding. After completing six months of anticoagulation, he was able to return to non-contact exercise like running, conditioning, and weightlifting for the rest of football season. For next football season, he was cleared to return to full contact football off anticoagulation with prophylactic aspirin when traveling to away games and continues to have close follow-up with the team.

Author's Comments:
We recommend keeping a broad differential for rib pain and pursuing further work-up based on clinical suspicion to make a timely diagnosis. He was seen in the training room three times prior to his final diagnosis. During the first visit, venous thromboembolism was included as part of the differential diagnosis, but the leading differential was musculoskeletal etiology given normal vitals, negative pulmonary embolism rule-out criteria score, improving symptoms, and workout as the triggering event. During the second visit, only musculoskeletal etiology was considered. During the third visit, pulmonary etiology was in the differential, which prompted further workup including CT angiography of the chest to evaluate for pulmonary embolism. This case highlights the importance of early diagnosis and treatment of pulmonary embolism and deep vein thrombosis due to increased morbidity and mortality if left untreated.

Editor's Comments:
Rib and chest pain can have a multitude of differential causes. As a sports medicine expert, we need to keep a high suspicion for uncommon reasons when the "usual suspects" do not apply.

References:
Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Advances. 2020;4(19):4693-4738. doi:https://doi.org/10.1182/bloodadvances.2020001830


Duration of Anticoagulation Post-PE: Things to Consider. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2019/03/22/07/45/duration-of-anticoagulation-post-pe

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