Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited. Pulmonary embolism in a patient with apical ballooning syndrome Francesco Fedele and Maria C. Gatto J Cardiovasc Med 2012, 13:56–59 Keywords: apical ballooning syndrome, pulmonary embolism, pyelonephritis University of Rome ‘Sapienza’, Department of Cardiovascular, Respiratory, Nephrological and Geriatic Sciences, Rome, Italy Correspondence to Maria C. Gatto, Department of Cardiovascular, Respiratory, Nephrological and Geriatic Sciences, ‘Sapienza’ University of Rome, Policlinico Umberto I, Viale del Policlinico 155, Rome 00161, Italy E-mail: mariachiaragatto@hotmail.com Received 13 April 2010 Revised 21 December 2010 Accepted 21 January 2011 To the editor The classic manifestation of pulmonary embolism with tachycardia, hypoxia, pleural chest pain and electrocar- diographic changes 1 represents a small fraction of pre- sentations of pulmonary embolism. The integration of clinical signs, laboratory tests and radiological imaging is required in order to make a correct diagnosis. In approxi- mately 25% of patients, the first manifestation of pul- monary embolism is unexpected death. Most pulmonary embolism is due to deep venous thrombosis (DVT), 2,3 only a small fraction is caused by other matter carried in the circulatory system. Belonging to this tiny group are gaseous emboli, neoplastic emboli, fatty emboli, septic emboli, foreign bodies and also some nanoparticles. 4 Methods A 65-year-old woman, on holiday in Rome, presented to the Emergency Department with flank pain, vomiting and profuse perspiration. Her medical history included diabetes mellitus type II, hypertension and new-onset hemorrhagic cystitis, which was treated with ciproflox- acin. A few days before she had had a shivering fever with profuse perspiration. Her initial vital signs were: tempera- ture of 36.58C, heart rate of 90 beats/min, blood pressure of 80/50 mmHg, respiratory rate of 13 breaths/min, and oxygen saturation of 97.2% on room air. The ECG recording showed sinus rhythm, heart rate of 90 beats per minute, ST-segment changes in D 1 , aVL, V 1 and V 2 that may be indicative of trans-mural ischemia, also in the absence of symptoms (Fig. 1a). The Emergency Research letter Fig. 1 Electrocardiographic changes. (a) Conventional 12-lead ECG shows sinus rhythm and heart rate of 90 beats per minute with ST-segment changes in D 1 , aVL, V 1 and V 2. (b) Conventional 12-lead ECG shows sinus tachycardia and heart rate of 100 beats per minute with ST elevation in D 1 , aVL, V 2 and V 3 . 1558-2027 ß 2011 Italian Federation of Cardiology DOI:10.2459/JCM.0b013e328344e682