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Non-massive pulmonary embolism — SCE Acute Medicine MCQ

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HardAcute Respiratory PresentationsNon-massive pulmonary embolismSCE Acute Medicine

A 52-year-old has 8 days of fever, splenomegaly, Hb 82 g/L, neutrophils 0.7 × 10⁹/L, platelets 44 × 10⁹/L, ferritin 38,000 micrograms/L, triglycerides 4.1 mmol/L and fibrinogen 0.9 g/L. Cultures are negative and organ dysfunction is progressing. Marrow sampling is planned. What is the best next step?

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Correct answer: E — Activate the HLH pathway and start syndrome-directed treatment now

Explanation lettering: B = shown as A · C = shown as B · D = shown as C · E = shown as D · A = shown as E

A is correct. The fever, splenomegaly, cytopenias, extreme ferritin, hypertriglyceridaemia and hypofibrinogenaemia make HLH highly probable and progression is time critical. Same-day haematology/HLH-network involvement, trigger investigation and syndrome-directed treatment should not wait for a marrow feature that may be absent. B gives a non-sensitive pathological finding veto power. C is unsafe because infection may trigger HLH and both processes can need treatment. D invents a ferritin threshold. E treats only one downstream inflammatory effect. Treatment is individualised to trigger and severity, commonly including corticosteroid-based therapy and selected additional agents.

Reference: GIRFT: haemophagocytic lymphohistiocytosis guide: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2024/07/HLH-Guide-final-version-v1.1-July-2024.pdf