A 21-year-old woman presented to the emergency department with severe dyspnea, hypotension (83/46 mmHg), tachycardia (152 beats/min) and upper abdominal pain. Her medical history included familial predisposition for pulmonary embolism. Except dull pain in the right upper abdomen, physical examination was unremarkable. D-dimer, NT-proBNP, troponin T, alanine and aspartate transaminases were elevated and ECG showed S1Q3T3 pattern. Emergency ultrasound revealed massive dilatation of the right atrium and ventricle with a floating thrombus in the inferior caval vein and inhomogeneous liver parenchyma.