An unusual case of hypoxemic respiratory failure in a preterm neonate

Pulmonary thromboembolism (PTE) in neonates is a serious yet underdiagnosed complication with challenging diagnostic workup. The incidence of neonatal thrombosis is 2.4 per 1000 NICU admissions of which 45 % to 55 % of cases occur in premature neonates. Venous thrombosis is more common than arterial thrombosis. The incidence of pulmonary thromboembolism (PTE) in the newborn period was about 14 % in one retrospective autopsy study. Our patient is a preterm infant who was on room air and presented with acute refractory hypoxemia at 3 weeks of life. The patient's pulmonary hypertension was unresponsive to maximal conventional therapies. However, a careful review of the initial echocardiogram obtained at the time of decompensation revealed a large bilateral pulmonary thromboembolism. After extensive multidisciplinary discussions, thrombolysis was used despite the risk of significant intracranial bleeding. This case highlights the cautious and successful use of thrombolysis in neonates with pulmonary thromboembolism leading to excellent clinical results and normal neurodevelopmental outcomes. The discussion focuses on the management of pulmonary thromboembolism in neonates.