Can dullness to percussion be present with a pulmonary embolism (PE)?

Dullness to Percussion in Pulmonary Embolism

Yes, dullness to percussion can be present in pulmonary embolism (PE) when it leads to complications such as pulmonary infarction with associated pleural effusion. 1

Pathophysiological Basis

Pulmonary embolism can lead to several complications that may cause dullness to percussion:

1. Pleural Effusion:

   • PE can cause pleuritis and pleural effusion (usually mild) as part of the clinical presentation known as "pulmonary infarction" 1
   • These effusions develop due to inflammatory processes at the site of embolism

2. Pulmonary Infarction:

   • Occurs when emboli cause alveolar hemorrhage
   • Can lead to consolidation of lung tissue
   • May progress to more severe complications in rare cases

Clinical Correlation

The presence of dullness to percussion in PE is typically associated with:

• Distal emboli causing pulmonary infarction 1
• Pleural irritation leading to effusion
• Areas of consolidation secondary to hemorrhage

In one unusual case report, PE led to a sequence of infarction, cavitation, abscess formation, and bronchopleural fistulation with development of stony dull percussion and absent breath sounds 2. While this represents an extreme presentation, it demonstrates how PE can evolve to produce significant physical examination findings including dullness to percussion.

Important Clinical Considerations

• Dullness to percussion is not among the common or classic findings in PE
• More typical signs and symptoms of PE include:
  • Dyspnea (80-89%)
  • Chest pain (40-60%)
  • Tachypnea (70%)
  • Syncope (14-19%)
  • Hemoptysis (7-11%) 3

Diagnostic Implications

Finding dullness to percussion in a patient with suspected PE should:

1. Not rule out PE (as it can occur with complications of PE)
2. Prompt consideration of alternative or additional diagnoses
3. Guide imaging selection (CTPA remains first-line for PE diagnosis with 90% sensitivity and 95% specificity) 3

Clinical Pitfall to Avoid

The presence of dullness to percussion might lead clinicians to focus exclusively on diagnoses like pneumonia or pleural effusion, potentially missing PE as the underlying cause. Remember that PE can present with non-specific symptoms and signs 4, and its clinical presentation may overlap considerably with other cardiovascular and pulmonary diseases 5.

When encountering dullness to percussion in a patient with risk factors for venous thromboembolism, maintain a high index of suspicion for PE, especially if the patient has unexplained dyspnea, pleuritic chest pain, or hemoptysis.