ABSTRACT
INTRODUCTION: Acute pulmonary embolism (PE) is the third most common type of cardiovascular disease in the United States, resulting in 60,000-300,000 deaths per year. Hormone use is a well-known risk factor for venous thromboembolism (VTE), including PE, in women. Less is known about the risk of VTE in men using oral hormonal agents. DESCRIPTION: A 69 year old male with a history of chronic obstructive pulmonary disease, congestive heart failure, traumatic brain injury, post-traumatic stress disorder, vascular dementia, depression, and on medroxyprogesterone 10 mg daily for sexual behavior disorder presented to our hospital with erratic behavior. On admission, he was found to be hypoxic with an oxygen saturation of 86% on room air and a fever of 39.5degree C. He had no previous sick contacts and had a negative COVID-19 PCR test. His chest X-ray showed no acute findings. Oxygen was initiated for hypoxemic respiratory failure at 15 L/min. Laboratory findings included an elevated D-dimer (13.03 mg/L) and his BNP (96 pg/mL) and troponin (6 ng/L) were within normal limits. A CT-PE revealed a large saddle embolus with extension of bilateral lower lobar arteries. There was no evidence of right heart strain and the patient was started on heparin. On day 3 of intensive care unit admission, the patient developed worsening hypoxia requiring high flow nasal cannula of up to 100% and hypotension. Therefore, he was referred for catheter-directed thrombolysis (EkoSonic endovascular system or EKOS). The patient continued to improve clinically and was discharged to a skilled nursing facility after a twelve day hospitalization and was to be continued on apixaban 5 mg twice daily. DISCUSSION: VTEs are a complication of oral contraceptive use and hormone replacement therapy. Unlike progestin-only pills (POPs) contraception, therapeutic POPs have been associated with a 5- to 6-fold increased risk of VTE compared with nonusers. This may possibly reflect a progestin dose-response effect. Medroxyprogesterone may be used for sexual behavior disorders. To our knowledge, this is the first reported case of a submassive PE associated with medroxyprogesterone use in a male patient.