Atypical Chest Pain
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CASE REPORT Atypical chest pain Magdalena Stachura, Janusz Dubejko Department of Cardiology, Division of Cardiologic Critical Care, the Ministry of Interior and Administration Hospital, Lublin, Poland KEY WORDS AbSTRACT chest pain, Chest pain is a common reason why patients seek medical consultation. Chest pain can be caused osteoporosis, by life-threatening diseases and requires extensive diagnostic evaluation, especially to exclude acute vertebral compression cardiac pathologies. However, in the case of atypical chest pain with a normal electrocardiogram and serum levels of myocardial necrosis markers with in the reference ranges, non-cardiac causes of chest pain should be considered. This report describes the case of a 90-year-old female patient with recurrent chest pain who was eventually diagnosed with osteoporotic vertebral fractures of the thoracic spine. INTRODUCTION Chest pain may be induced by weakness and advanced gonarthrosis), and since various diseases commonly including different the night before the admission the pain had been forms of coronary artery disease. However, when more intense and had become steady. It did not the pain is a typical nature, and is not associated radiate to other regions of the body, was not po- with elevated serum levels of myocardial necrosis sition related and did not enhance with inspira- markers or acute ischemic changes on electrocar- tion. The pain was partly relieved with nitroglyc- diogram (ECG), it is necessary to pay special at- erin administered by the emergency doctor. Con- tention to its potential non-cardiac causes. Clin- comitant diseases included long-term arterial hy- ical evidence indicates that 50% of all patients pertension, paroxysmal atrial fibrillation, chronic admitted to the hospital with an initial diagno- heart failure. Several years before the admission sis of unstable angina have non-cardiac diseas- the patient underwent surgery and radiotherapy es. Other causes which should be considered in for tongue cancer. During the previous 1–2 years, differential diagnosis of chest pain include aor- the patient was several times hospitalized in the tic dissection or penetrating aortic ulcers, pul- departments of cardiology for similar signs and monary embolism, pericarditis, pneumonia or symptoms, each time acute myocardial necrosis or pleuritis, pneumothorax, mediastinal emphyse- new-onset ischemic ECG changes were excluded; ma, esophageal spasm, esophagitis or rupture of emergency computed tomography of the thoracic the esophagus, gastroesophageal reflux disease, aorta during one of the hospitalizations showed gastric ulcers with imminent ulcer perforation, calcified aortic plaques and cardiac enlargement. biliary tract diseases, acute pancreatitis, herpes The diameter of the aorta was normal with no Correspondence to: zoster, Tietze's syndrome, fractured ribs, com- signs of wall dissection. The patient was taking Magdalena Stachura, MD, Oddział Kardiologii z Pododdziałem pression vertebral fractures, intercostal neural- on a long-term basis such medications as furo- Intensywnej Opieki Kardiologicznej, gia, pectoral muscle pain, sickle cell crisis, and semide, losartan, isosorbide mononitrate, mol- Szpital MSWiA, ul. Grenadierów 3, psychiatric disorders.1,2 sidomine, verapamil and potassium supplemen- 20-331 Lublin, Poland, phone: +48-81-728-42-70, tation, and since her most recent hospitalization, fax: +48-81-728-56-98, Case report A 90-year-old patient was admit- also a proton pump inhibitor. Physical examina- e-mail: [email protected] ted to the Department of Cardiology, Division of tion showed that the patient was in a relatively Received: May 2, 2008. Cardiac Critical Care of the Ministry of Interior good condition; her weight was normal, she had Revision accepted: July 9, 2008. Conflict of interest: none declared. and Administration Hospital in Lublin because of a normal size thyroid gland, a 102/min irregular Pol Arch Med Wewn. 2008; pain in the anterior chest wall. The patient self-re- heart rate, with a pulse deficit, and a silent systol- 118 (11): 675-678 ported that the pain had occurred periodically for ic cardiac murmur upon auscultation of the mi- Translated by Elżbieta Cybulska, MD Copyright by Medycyna Praktyczna, several months, while walking and at rest (the pa- tral region, single crepitations on auscultation of Kraków 2008 tient used a walker because of generalized muscle the base of both lungs. The peripheral pulse rate CASE REPORT Atypical chest pain 675 was irregular, about 95 beats/min. THe volume massive degenerative productive lesions of verte- and strenght of the pulse wave were normal. On bral edges. As suggested by the radiologist there palpation the bilateral mammary glands were was a suspicion of an osteolytic lesion of the Th9 normal, the abdomen was soft, not tender, and vertebral corpus, but abdominal and breast ultra- there was a slight edema of the ankles and lower sonography did not show any abnormalities. Pa- extremities. The arterial blood pressure measured racetamol and tramadol administered as the pain on the upper left extremity was 130/75 mmHg, relieving treatment resulted in a significant allie- and 125/70 mmHg, on the right. Rapid atrial fi- vation in pain sensation. After the consultation brillation was present on the ECG. Left axis devi- with a specialist, the patient was referred to the ation, intermediary position of the heart, and fea- Orthopedic Outpatient Clinic of the Ministry of tures of subendocardial ischemia in leads I, aVL, Interior and Administration Hospital in Lublin V5, V6 were revealed. Laboratory examinations for anti-osteoporosis treatment. excluded acute myocardial ischemia. The results of other laboratory examinations were: total pe- Discussion Pain characteristics may be useful ripheral blood count – normal, erythrocyte sed- in making decisions regarding potential causes imentation rate after 1 hour (32 mm), glucose ofatypical chest pains. Constrictive, squeezing or (138 mg/dl), natrium (140 mmol/l), potassium burning pain or that described as an uncomfort- (3.48 mmol/l), chlorides (104 mmol/l), creatinine able chest pressure, in response to exercise, cold [(1.37 mg/dl), glomerular filtration rate accord- air, a meal or emotional stress, localized behind ing to MDRD 38 ml/min/1.73 m2], total choles- the sternum, penetrating through the chest inte- terol (160 mg/dl), low-density lipoprotein choles- rior, radiating to the shoulders, both arms, intras- terol (97 mg/dl), high-density lipoprotein choles- capular area, forearms, the neck, jaws, teeth, asso- terol (55 mg/dl), triglycerides (140 mg/dl), biliru- ciated with nausea, vomiting or excessive sweats, bin (0.17 mg/dl), aspartate transaminase (16 U/l), indicates an ischemic nature of the signs.1,2 Addi- alanine transaminase (12 U/l), serum thyroid- tional risk factors including systolic arterial blood stimulating hormone (0.979 µIU/ml). The uri- pressure below 110 mmHg, lung crepitations, sta- nalysis showed: specific gravity (1015 g/l), acid- ble ischemic heart disease, myocardial infarction, ic, transparency (cloudy), protein (0.033%), nor- and previous percutaneous transluminal coro- mal urobilinogen; glucose, ketone and bilirubin nary angioplasty or coronary artery bypass sur- absent; the microscopic analysis demonstrated gery, and pain the nature of which resembles that numerous polygonal epithelial cells, 1–2 round of the previous myocardial infarction, suggests cells/HPF, white blood cells covering HPF, 20– ischemic etiology.3 Pain relief after nitroglycer- 25 dysmorphic and isomorphic RBC/HPF, abun- in administration is not specific for retrosternal dant bacteria and numerous yeast cells. Poster- pain. The prospective study of 270 patients who oanterior chest radiograph showed mild cardiac reported to the hospital emergency department enlargement, perihilar vascular densities, athero- because of chest pain demonstrated that the sen- sclerotic plaques within the aortic arch, and no sitivity of nitroglycerin administration test in di- pulmonary parenchymal infiltrations. agnosing the chest pain was 72%, while its spec- On admission the sinus rhythm returned spon- ificity was only 37%.4 There is evidence suggest- taneously, the subendocardial ischemia features ing that up to 20% of chest pain may be caused by present on the ECG taken during arrhythmia epi- the musculoskeletal diseases. The most common sode significantly subsided, however the chest include prolapsed cervical intervertebral disc, re- pain persisted. Because of normal troponin T le- striction of the intervertebral joints or costal mo- vels, and creatine kinase-MB serum activity, and bility and intercostal neuralgia. Shoulder joint de- the a typical character of pain, special attention generative lesions, spondylocystitis, osteoporot- was given to the differential diagnosis of anterior ic fractures and bone tumors are the causes that chest wall pain reported by the patient. Conside- less commonly are manifest in this manner. In ring tenderness of the costosternal osteochondral some cases these diseases may also be manifested junction region on palpation, and the absence of by chest pain radiating to the upper left extremi- thoracic spine tenderness on percussion, a suspi- ty.5 Compression of the nerve roots by interver- cion of Tietze's syndrome as a potential cause of tebral disc herniation or vertebral osteophytes complaints was taken into account, and a nonste- may result in pain radiating to the chest, with roidal anti-inflammatory drug was administered occasionally accompanying