Silent Pulmonary Embolism in a Low-Risk Young Adult: A Case Report of Missed Diagnosis Behind Atypical Chest Pain

BACKGROUND Pulmonary embolism (PE) can present with highly variable symptoms, often leading to delayed diagnosis, particularly in young, low-risk individuals without classical features. Pleuritic chest pain, although common in peripheral PE, is frequently misattributed to benign causes, especially when reproducible on palpation. This case illustrates a diagnostic pitfall in evaluating chest pain and underscores the importance of a structured clinical assessment. CASE PRESENTATION A 38-year-old male software engineer presented with a 5-day history of sharp, right-sided pleuritic chest pain. He was hemodynamically stable, afebrile, and denied dyspnea or other cardiopulmonary symptoms. The pain was reproducible on palpation, leading to an initial diagnosis of musculoskeletal chest wall pain. However, due to symptom persistence and an elevated D-dimer (1.20 µg/mL), computed tomography pulmonary angiography was performed and revealed a segmental PE in the right lower lobe with associated wedge-shaped subpleural consolidation consistent with pulmonary infarction. The patient was managed as an outpatient with rivaroxaban and remained symptom-free at follow-up. Thrombophilia testing was deferred. DISCUSSION This case demonstrates how anchoring bias and low pre-test probability may delay critical diagnoses in younger patients. Reproducible chest pain does not exclude PE, and persistent pleuritic pain warrants structured evaluation. Segmental emboli and infarctions are more common in younger populations and may present without dyspnea or hypoxia. CONCLUSION Clinicians must maintain a high index of suspicion for PE in patients with pleuritic chest pain, regardless of age or apparent risk, and should use validated decision tools to guide imaging and treatment decisions.