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Blood loss and massive pulmonary embolism: case report A 51-year-old man developed massive pulmonary embolism during treatment with desmopressin for diabetes insipidus and testosterone for langerhans cell histiocytosis (LCH). Additionally, he developed blood loss during treatment with alteplase for pulmonary embolism [routes, doses and duration of treatments to reactions onset not stated; not all frequencies of administration stated]. The man, who had right ear pain and a rash in his groin since 10 months, presented to clinic. He received several treatment with antibiotics and steroids; however, there was no improvement. On further examination, he was diagnosed with LCH along with BRAF N486_P490del in-frame deletion mutation. He was hospitalised. Furhter examinations showed heterogeneously enhancing mass within the pons, medulla, cerebral peduncles and hypothalamus as well as occlusion of both external auditory canals. Therefore, he was started on prophylactic therapy with unspecified low molecular heparin. Further examinations revealed low levels of testosterone and thyroid stimulating hormone. His overall findings were significant with hypopituitarism secondary to infiltrative LCH. Therefore, he was started on desmopressin every 12h and testosterone gel along with levothyroxine sodium [levothyroxine]. Additionally, he was started on cladribine. Following 1 cycle of cladribine, he was discharged on an unspecified endocrinology medications and antimicrobial prophylaxis. Before initiation of the second cycle, a remarkable clinical improvement along with near resolution of skin lesion was noted. Then the second cycle was initiated. After 14 days of the second cycle, he presented to clinic with cough and shortness of breath. His vital signs were within normal limts and chest x-ray did not show any acute process. Considering the infectious aetiology, he was started on empirical treatment with azithromycin. Following 3 days, he presented to the emergency department with worsening chest tightness and pain. On arrival, he was hypotensive, tachycardic and hypoxic. A CT angiography revealed a large saddle pulmonary embolism with significant right ventricular strain. Based on these findings, a diagnosis of massive pulmonary embolism was made. The man was treated with heparin and a pulmonary embolism response team was contacted. He was a poor candidate for systemic lytics due to intracranial lesions. Therefore, a peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) and a mechanical thrombectomy by interventional radiology (IR) were planned. During procedure, it was noted that the clot was highly organised and rigid, and it was unable to remove easily with suction thrombectomy. As a result, it was decided to perform catheter-directed localised thrombolysis. An ekosonic endovascular system (EKOS) catheter was placed along with infusion of alteplase over 12h with plans to perform an additional attempt at thrombectomy. Before initiation of IR, a routine wound care evaluation was performed, which showed sever