Chest Pain in a Football Strength Coach

Abstract

HISTORY: A 29-year-old adopted, African American male football coach traveled with the football team to Colorado to hike Pikes Peak. At 14,000 feet, he developed mid-sternal chest pain that radiated to his left upper abdomen and left shoulder. The pain worsened with deep breathing and exertion. He presented to a local ED, where a CT abdomen/pelvis revealed splenomegaly. Routine labs revealed a mild anemia and thrombocytopenia. Upon returning home, the pain continued for 2 days so he presented to clinic. There, he denied calf pain, extremity swelling, fever, nausea, palpitations, vomiting, hematuria, and syncope. He denied taking medications, supplements, and alcohol/drugs. He reported developing similar symptoms in 2015, also when hiking. At that time, he was diagnosed with pericarditis with symptom resolution in a few days. PHYSICAL EXAMINATION: Temp 36.9F, BP 132/61, HR 67, RR 16, O2 sat 97% At rest, he was alert and comfortable. Breathing comfortably with symmetric aeration; no wheezing or crackles. Heart had regular rate and rhythm, without murmur. Abdomen was soft and non-distended, though he was tender to palpation in the left upper quadrant. No lower extremity edema; calves were symmetric and non-tender to palpation. DIFFERENTIAL DIAGNOSIS: Pulmonary Embolus Pericarditis Mononucleosis Sickle cell crisis in a patient with sickle cell trait TEST AND RESULTS: A CT angiography chest, chest radiograph, and abdominal ultrasound were obtained and were notable for splenomegaly (14.3cm); otherwise unremarkable. An EKG revealed sinus bradycardia with sinus arrhythmia. Labs were obtained including CBCPD, CMP, CK, haptoglobin, LDH, and hemoglobin electrophoresis, and notable for a mild anemia (hemoglobin 12.2), thrombocytopenia (platelets 52), mild transaminitis (AST 42, ALT 37), and evidence of hemolysis (haptoglobin < 10, LDH 486, CK 348). Hemoglobin electrophoresis was consistent with sickle cell trait. FINAL WORKING DIAGNOSIS: Sickle cell crisis in a patient with sickle cell trait TREATMENT AND OUTCOMES: 1. Trended labs for 2 weeks. 2. Avoid strenuous activity until pain resolved. 3. Provide counseling regarding hydration, heat illness, and training especially at altitude. 4. Follow up with hematology. 5. Consider screening NCAA coaches/athletic trainers given NCAA athletes are screened for sickle cell.