Introduction
Acute pulmonary thromboembolism is a life-threatening cardiovascular condition with high mortality. In intermediate risk pulmonary embolism (PE), management strategy may include catheter-directed (CD) thrombolysis in addition to systemic anticoagulation. Immediate systemic thrombolysis is considered if clinical deterioration and shock ensues. When hemodynamically stable, heparin infusion is the mainstay of therapeutic anticoagulation with potential complications. Heparin-induced thrombocytopenia (HIT) is a rare but potentially fatal, antibody-mediated adverse drug reaction of heparin therapy. It occurs among 1% of hospitalized patients receiving heparin and the mortality rate is as high as 20% [1]. We present the unusual clinical course a patient with acute intermediate risk bilateral pulmonary thromboemboli who developed HIT and required additional management strategies due to rapid conditional change.