Co-occurrence of hampton's hump, westermark sign and palla's sign in acute pulmonary embolism

We present a case of a 32-year-old woman with history of tobacco smoking and non-ischemic cardiomyopathy secondary to methamphetamine use. She presented first to outside hospital complaining of shortness of breath, hemoptysis, and lower extremity edema for the last 3 days. During the first assessment she was hemodynamically unstable and was approached as a possible pneumonia vs pulmonary embolism (PE). She was started on ceftriaxone, azithromycin, and full dose anticoagulation and was transferred to our facility for higher level of care in the Medical Intensive Care Unit (MICU). On admission, her vital signs and labs included HR: 123 bpm, RR: 29 rpm, BP: 85/52 mmHg, O2 Sats: 98% on 40% FIO2 high flow nasal canula, Hg: 11.4 g/dl, WBC: 11.4 k/dl, PLT: 334 k/dl, lactate: 2.4 mmol/l. Her chest x-ray (CXR) (Fig. 1) showed a lateral wedge-shaped opacity (black arrow) in the right peripheral lung (Hampton's hump), a focal area of oligemia (space between white arrows heads) in the right lower zone (Westermark's sign), and a prominent right descending pulmonary artery (red arrow, Palla's sign). Computed tomography of the chest with contrast showed bilateral segmental PE involving all lobes (Fig. 2). Echocardiogram transthoracic showed an EF <20% and dilatation of heart chambers. The patient was fluid resuscitated and was started on an alteplase 100 mg bolus and enoxaparin 1 mg/kg twice a day. After 3 days in the MICU, the patient was transferred to the step-down unit for stabilization of her heart failure.