Football Athlete with Chest Pain and Dysphagia

Abstract

HISTORY: 22 year old collegiate football player was seen in clinic for several years of intermittent dysphagia with associated chest pain. Symptoms had occurred 3-4 times annually, but athlete had noted increasing frequency over the past several weeks with occasional associated heartburn. He was initially treated with oral omeprazole 40 mg daily for presumed gastroesophageal reflux disorder. Two weeks later, following an intense practice, he developed severe, burning, substernal chest pain and diaphoresis which prompted emergency department evaluation for possible cardiac etiology. PHYSICAL EXAMINATION: Vitals: HR 56, BP 147/90, RR 18 General: Uncomfortable, writhing on exam table Neck: Supple. No lymphadenopathy. CV: Regular rate and regular rhythm with no murmurs. No friction rub heard. Distal pulses are intact. No lower extremity edema. Pulmonary: No respiratory distress. Lungs are clear to auscultation bilaterally. Abdominal: Soft, non-tender, non-distended. DIFFERENTIAL DIAGNOSIS: GERD Esophageal stricture Esophageal spasm Acute coronary syndrome Myocarditis/Pericarditis Coronary or aortic dissection TESTS AND RESULTS: WBC 5.5, HGB 13.7 Troponins- 0.09, 0.24, 3.63 (peak) CRP 0.2, ESR 9 Creatinine 1.8 CK (peak) 836 ECG: interpreted as having diffuse ST elevation Subsequent ECG: precordial J point elevation without concave ST elevations Echocardiogram: left ventricular ejection fraction of 45-50% Cardiac MRI: Small areas of focal mid-wall, late gadolinium enhancement (LGE) consistent with myocarditis Barium swallow study: transient “feline esophagus” without diverticulum or stricture EGD: longitudinal furrows with punctate white spots. Biopsies revealed increased intra-epithelial eosinophils up to 50 per hpf TSH 1.06 ANA, ANCA, Anti-SCL 70, C4 all negative FINAL WORKING DIAGNOSIS: Presumptive Viral Myocarditis Eosinophilic Esophagitis (EoE), biopsy-proven TREATMENT AND OUTCOMES: Placed on medical hold for remainder of football season Repeat cardiac MRI improved Returned to light weightlifting and easy spinning without recurrence of symptoms. Will be reevaluated by exercise stress test and echocardiogram before further return to sport decisions are made Remains on twice daily omeprazole 40 mg for management of his EoE until follow up with GI.