Sudden Acute Thoracic Pain and Hypovolemic Shock As a Presentation of Spontaneous Rupture of Intercostal Artery: A Case Report

Abstract

Spontaneously expanding pleural or abdominal hematomas are an uncommon, but potentially life-threatening, condition occurring especially in elderly adults with cardiovascular disease or receiving anticoagulant therapy.1 A 85-year-old woman was admitted to the hospital complaining of severe dyspnea and dysphonia (the latter having started several months earlier). Her complex medical history included arterial hypertension, type 2 diabetes mellitus, coronary heart disease with previous myocardial infarction, chronic kidney disease, autoimmune thrombocytopenia, severe aortic stenosis, and pulmonary hypertension. She also had a mitral biologic valve and a cardiac pacemaker. At admission, she was alert, oriented, and apyrexial. Physical examination revealed arterial blood pressure of 145/90 mmHg, regular heart beat (75 beats/min) with systolic mitroaortic heart murmur (intensity: 3/6 on the Levine scale), and bilateral moist rales. Abdominal examination was normal, and an evident dysphonia with barking cough was also present. Blood chemistry panel showed white blood count 8,000/mm3 with 60% neutrophils, hematocrit 42%, hemoglobin (Hb) 12.2 g/dL, platelets 106,000/mL, sodium 143 mEq/L, potassium 3.7 mEq/L, glucose 135 mg/dL, creatinine 1.1 mg/dL, alanine transferase 20 U/L, prothrombin time (PT) 1.01 international normalized ratio (INR); T-troponin assay was negative, and urinalysis was normal. The patient started treatment with ramipril, carvedilol, loop and antialdosteronic diuretics, insulin, clopidogrel, and low-molecular-weight heparin. The otorhinolaryngologic visit showed left vocal cord paralysis, and thoracomediastinic computed tomography (CT) revealed the presence of a heart thrombus, located in the left atrium. Echocardiogram confirmed this finding, and warfarin anticoagulant therapy was started. Two days later, she complained of a severe sudden thoracic pain, at the posterior right hemithorax, quickly followed by sudden onset anemia (Hb 12.2 → 6.2 g/dL), secondary to blood loss, and hypovolemic shock. Coagulation tests did not appear significantly altered (PT INR 1.48, partial thromboplastin time 1.50; normal ratio 0.85–1.20), and correction of hypovolemia was reached with intravenous fluids and blood transfusion (six units). Urgent CT revealed the presence of a wide expanding hematoma (Figure 1A) secondary to a rupture of the tenth right intercostal artery that was successfully treated with angiographic embolization with polyvinyl alcohol particles (250–300 μm) and platinum coil positioning (Figure 1B and C). There was rapid improvement of the clinical picture, with stable hemodynamic condition. A few days later, the patient was discharged in general good health. Spontaneous pleural or abdominal hematoma, secondary to arterial rupture, has been reported in cases associated with coarctation of the aorta and neurofibromatosis2 and trauma,3 even if mild,4 such as bouts of coughing.5, 6 As for spontaneous rupture of intercostal arteries, a limited number of cases have been described in the literature, with reference to the right twelfth,7 right fifth,8 and left tenth9 intercostal arteries. These were in elderly adults, and sudden pain was the main onset symptom. In all cases, angiography and therapeutic embolization allowed an uneventful recovery. In elderly people, the occurrence of sudden thoracic or abdominal pain, sometimes after coughing or sneezing, associated with anemia or hypotension, should immediately alert the clinician to the possibility of an arterial rupture with hematoma. Angiographic embolization is a proven effective alternative to thoracotomy and should be the first choice in selected patients.10 Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Raffaella Salmi: Original idea, acquisition of data, patient care, literature search, preparation of manuscript. Piergiorgio Gaudenzi, Franco Ricci, Maria Cristina Gnani, Pierluigi Morandi, and Filippo Di Todaro: Acquisition of data, patient care, literature search. Roberto Galeotti: Radiological intervention, literature search, preparation of part of the manuscript, preparation of the paper. Roberto Manfredini: Original idea, acquisition of data, literature search, and preparation of manuscript. Sponsor's Role: None.