ATYPICAL PRESENTATION OF AORTIC DISSECTION DURING COVID-19 PANDEMIC

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Aortic dissection (AoD) is extremely rare, with an annual incidence of 2.5-3.5 per 100,000 persons and a mortality rate between 13% - 50%. AoD commonly presents with either sudden onset chest pain or back pain, with systemic hypertension being the most significant predisposing risk factor. We report an atypical presentation and unfortunate misdiagnosis of aortic dissection during the COVID-19 pandemic that could further improve this patient population's screening and outcomes. CASE PRESENTATION: A 59 year old male with a history of hypertension was transferred to our institution for Neurosurgery evaluation due to head CT results consistent with subarachnoid hemorrhage. Repeated images revealed normal findings. Upon arrival, he presented with blood pressure readings of 252/110 mmHg accompanied by altered mental status. Further questioning of the patient's spouse revealed the patient's non-compliance with his antihypertensives, and abuse of energy drinks (> 4 drinks/day). In addition she revealed that symptoms began one day prior to admission, as the patient stood in the living room and reported an intense, non-localized headache accompanied by loss of sensation in lower extremities and loss of consciousness. Physical examination was remarkable for obesity, drowsiness, epigastric tenderness, and no focal neurologic deficits. The patient was admitted with an initial diagnostic impression of hypertensive emergency with the CNS as target for which Clevidipine drip was started. Given the marked clinical deterioration 48 hours after admission consisting of an elevated temperature, tachycardia, and leukocytosis during the COVID-19 pandemic led to suspicion, PCR testing and isolation. The PCR was non-reactive. Portable Chest X-Ray report yielded a magnification of cardiomediastinal silhouette with mediastinal widening. Subsequent chest and abdominal/pelvic CT confirmed the suspected diagnosis of AoD. Cardiology and Endovascular Surgery were consulted for further management. Recommendations were given against surgical management. After 35 days of hospitalization, the patient was discharged in a stable condition. DISCUSSION: AoD are caused by a tear in the aortic intima creating a false lumen. Despite the rarity of AoD, it has typical findings. Pain, most commonly in the chest and back, is present in over 90% of AoD patients, all of which were absent in our patient. Transient neurological symptoms including altered mentation;and elevated blood pressure readings, must be evaluated for aortic dissection when risk factors are present despite concurrent inflammatory responses amid a pandemic. CONCLUSIONS: A new pandemic and the surrounding uncertainty can influence but most not be allowed to sway other differential diagnoses. It is of utmost importance to recognize atypical presentations in high risk populations in order to obtain better outcomes. REFERENCE #1: Astarita A, Covella M, Vallelonga F, et al. Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis. J Hypertens 2020;38:1203. REFERENCE #2: Martin JF, Higashiama E, Garcia E, et al. Hypertensive crisis profile. Prevalence and clinical presentation. Arq Bras Cardiol 2004;83:131. REFERENCE #3: Clouse WD, Hallett JW Jr, Schaff HV, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc 2004;79:176 DISCLOSURES: No relevant relationships by Felix Aponte Santos, source=Web Response no disclosure on file for Andres Cordova Toro;No relevant relationships by Adriana Suarez Cruz, source=Web Response