Wheezing in an Asthmatic Woman: Worsening Asthma or Something Else?

A 44-year-old asthmatic woman presented to the emergency department with dry cough and dyspnea for 5 days. She had been started on oral corticosteroids and inhaled albuterol a few days earlier, without improvement. She had a history of depression and vertebroplasty earlier in the year. She reported a diagnosis of mild asthma with rare flare-ups and being more breathless than usual over the past 4 months. Physical examination revealed scattered wheezes but was otherwise unremarkable. A complete workup was performed, including a chest x-ray that revealed radiopaque material in the pulmonary vessels of both lungs (Figures 1 and 2), followed by a computerized tomography angiogram of the chest showing hyperdense material bilaterally in lobar, segmental, and subsegmental pulmonary arteries (Figures 3 and 4). A diagnosis of pulmonary cement embolism was made, which is a complication of vertebroplasty characterized by embolization of bone cement into the lungs. Careful review of the patient's medical history revealed that her dyspnea became more prominent after vertebroplasty. She was started on 6-month anticoagulant therapy with rivaroxaban, and follow-up with a pulmonologist was scheduled. Figure 2Chest X-ray, lateral view. (A) Before vertebroplasty. (B) After vertebroplasty; green arrows indicate the cement emboli. View Large Image Figure Viewer Download Hi-res image Figure 3Computerized tomography angiogram of the chest; green arrows indicate the cement emboli. (A) Cross-sectional image. (B) Cross-sectional maximum intensity projection reconstruction. View Large Image Figure Viewer Download Hi-res image Figure 4Computerized tomography angiogram of the chest; green arrows indicate the cement emboli. (A) Sagittal image. (B) Sagittal maximum intensity projection reconstruction. View Large Image Figure Viewer Download Hi-res image