clinical Just a sore throat?

Kam Cheong Wong

distress apart from a moderate sore throat. Keywords: diagnosis, differential; electrocardiography; case reports; heart diseases He is afebrile. His heart rate is 66 bpm, regular and his blood pressure is 122/80 mmHg. His tonsils and uvula are neither inflamed nor swollen. He has no cervical Case study lymphadenopathy. His lungs are clear on auscultation and his heart sounds are dual A man, 43 years of age, presents to his with no murmur. His electrocardiogram is general practitioner with a 6 day history of shown in Figure 1. sore throat. There are no other symptoms of an upper respiratory tract infection. In Question 1 passing, the patient mentions that 6 days ago he experienced an episode of exertional Describe any clinically important findings shown in chest pain. On further questioning it is the electrocardiogram (ECG) in Figure 1. found the chest pain was central with no radiation, it lasted 30 minutes, resolved Question 2 spontaneously and was associated with What is the likely pathology in this case? nausea. He did not seek medical assessment at the time and has no cardiac history. Question 3 He takes no regular medication and has How many patients with this problem present no allergies. He is an exsmoker with a 15 atypically? pack-year history (he quit 7 years ago) but has no other known cardiac risk factors. He Question 4 does not drink alcohol or take illicit drugs. On examination, he appears well built What are some of the atypical presentations of with a body mass index of 27. He is not in this problem?

I aVR V1 V4

aVL V2 V5 II

aVF V3 V6 III

25 mm/s 10.0 mm/mV 0.05–35 Hz

II

25 mm/s 10.0 mm/mV 0.05–35 Hz

Figure 1. ECG of patient presenting with sore throat and history of chest pain

Reprinted from Australian Family Physician Vol. 40, No. 5, May 2011 293 clinical Just a sore throat?

Answer 1 sore throat2–4 and toothache.5,6 Myocardial University of Western Sydney, New South ischaemia should be considered and excluded Wales. [email protected]. The ECG shows inferior T-wave inversions and in patients who present with any of these inferior Q-waves. Conflict of interest: none declared. symptoms, particularly patients with multiple Answer 2 cardiovascular risk factors or presentations References 1. Cemeron P, Jelinek G, Kelly A-M, et al, editors. where no pathology is found that explains Textbook of adult emergency medicine. 2nd edn. These ECG findings suggest a previous the patient’s symptoms. Typical and atypical Edinburgh: Churchill Livingstone, 2004. myocardial infarction. This patient’s subsequent presentations of myocardial infarction are listed 2. Auer J, Weber T, Berent R, et al. Throat pain as the only symptom of inferior wall myocardial coronary angiogram reveals multivessel disease in Table 1. infarction. J Otolaryngol 2006;35:424–6. including a 100% occluded proximal right 3. Abinader EG, Sharif DS, Omary M. Inferior wall coronary artery with collaterisation from the left Summary myocardial infarction preceded by acute exuda- tive pharyngitis in young males. Isr J Med Sci side. An echocardiogram shows a segmental left • Most patients with sore throat have an 1993;29:764–9. ventricular dysfunction with inferior/inferoseptal upper respiratory tract infection or another 4. iwata I, Dohke K. The symptom of sore throat in hypokinesis consistent with a recent myocardial local explanation for their pain. These myocardial infarct. Jibiinkoka1961;33:645–6. 5. okeson JP. Non-odontogenic toothache. infarction. This patient most likely has a chronic patients do not need ECGs or other cardiac Northwest Dentistry 2000;79:37–44. subtotal right coronary lesion that became investigations. 6. Kreiner M, Okeson JP. Toothache of cardiac origin. Journal of Orofacial Pain 1999;13:201–7. acutely occluded 6 days before his presentation, • Atypical presentations of myocardial producing the episode of chest pain. It is unclear infarction are relatively common, accounting whether the myocardial infarction caused the for 10–30% of cases. patient’s sore throat. • Patients with vague cardiac symptoms or atypical symptoms of a myocardial infarction Answer 3 may be more likely to present to their general It has been estimated that 10–30% of patients practitioner than to a hospital emergency with myocardial infarction have an atypical department. presentation.1 Although this particular • Patients with atypical presentations of case is very uncommon, it serves as a good myocardial infarction are likely to be reminder that atypical presentations can occur. unaware of the potential significance of their Importantly, in this case the examination findings symptoms, therefore GPs need a high index did not fit with an upper respiratory tract of suspicion. infection or other local cause of sore throat. Author Kam Cheong Wong MBBS, BE, MSc, FRACGP, is Answer 4 a general practitioner, medical educator, Beyond The atypical presentations of myocardial Medical Education, Clinical Senior Lecturer, infarction can include epigastric pain, nausea, University of Sydney and Conjoint Lecturer,

Table 1. Typical and atypical presentations of myocardial infarction Typical presentations Atypical presentations • Central chest pain • Abdominal or epigastric pain • Chest tightness • Lightheadedness with or • Chest heaviness without syncope† • Chest squeezing • Fatigue and/or weakness † • Chest pressure with or without syncope • Chest pain – may radiate to the jaw, neck, both • Sore throat arms (especially ulnar surface of forearm and • Toothache hand), back, and epigastrium* • Dyspnoea† • Nausea with or without vomiting • Diaphoresis * Rarely below umbilicus or above the mandible † Dyspnoea, fatigue, and faintness are more common in elderly and diabetic patients

294 Reprinted from Australian Family Physician Vol. 40, No. 5, May 2011