COCAINE-INDUCED AORTIC DISSECTION AND LEFT HEMOTHORAX

Abstract

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Aortic dissection is a rare and potentially lethal complication of cocaine use. Cocaine has been reported as a precipitating factor in 0.5% to 37% of aortic dissections depending on the patient population. Aortic dissection is seen at a frequency of 2.6-3.5 per 100,000 patient admitted for chest pain. Cocaine use is also associated with alveolar hemorrhage and hemothorax. We report a case of aortic dissection causing unilateral hemothorax and alveolar hemorrhage in a patient who was found to have smoked crack – cocaine while in the hospital for chest pain. CASE PRESENTATION: A 64 year old female with a past medical history of HTN and CAD presented to ED complaining of atypical chest pain with dyspnea following use of crack-cocaine. Her physical exam and vital signs were normal. She was admitted to cardiac telemetry unit for further work up. ACS and PE were ruled out by negative cardiac enzymes and normal V/Q scan. Forty-eight hours after admission, the patient was found unresponsive by nursing staff with a warm glass pipe at her bedside. The patient was noted to have agonal breathing with dilated and unresponsive pupils. Left sided breath sounds were absent on physical exam. She was intubated and a portable chest x-ray revealed complete white out of the L lung with mediastinal shift to the Right. Subsequent CT revealed an acute intramural hematoma of the aortic arch measuring up to 16 mm and an ascending aortic aneurysm measuring 4cm. Patient was admitted to ICU where she was found to have aortic and coronary arteries dissection with high troponin and bradycardia. On point of care US study she was found to have abdominal aortic dissection and and a large L pleural effusion. Her urine toxicology was positive for cocaine. Within 48 hours the patient expired. DISCUSSION: The exact mechanism of cocaine induced aortic dissection and hemothorax is not well known. Presumably, the sudden and profound hypertension that accompany cocaine usage causes a stressful force on the aorta intima leading to aortic dissection (5). Aortic dissection diagnosis is usually suspected clinically by obtaining detailed medical history and finding a difference of blood pressure between the patient’s arms. Widened mediastinum on chest x-ray is also suggestive of aortic dissection. Diagnosis is confirmed by TEE or CT angiography. Our case underlines the importance of maintaining a high index of suspicion for aortic dissection in patients presenting with chest pain especially in the setting of cocaine use. CONCLUSIONS: Although it is a rare cause of acute pathology, aortic dissection due to cocaine usage should be suspected in every patient admitted to the hospital for chest pain. Thorough medical history, physical exam, and imaging review are essential components for diagnosis Reference #1: Eagle, KA et al. Cocaine-related Aortic Dissection in Perspective. Circulation. 2002;105(13):1529-1530. Reference #2: Hsue, PY et al. Acute Aortic Dissection Related to Crack Cocaine. Circulation. 2002;105(13):1592-1595. Reference #3: Singh, S et al. Cocaine-related Acute Aortic Dissection: Patient Demographics and Clinical Outcomes. Canadian Journal of Cardiology. 2007;23(14):1131-1134. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Araz Baboujian, source=Web Response No relevant relationships by Sivacharan Buddhavarapu, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Kunal Nangrani, source=Web Response No relevant relationships by Matthew Peachey, source=Web Response No relevant relationships by jad sargi, source=Web Response No relevant relationships by John Zeibeq, source=Web Response