THE MONEY IS IN THE AIRWAY: AN ATYPICAL CASE OF NON-CARDIAC CHEST PAIN

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TOPIC: Signs and Symptoms of Chest Diseases TYPE: Fellow Case Reports INTRODUCTION: Foreign body aspiration is a common pathology in pediatric medicine but relatively infrequent in the adult population. Symptoms are usually those of acute airway irritation, including cough, dyspnea, and asphyxiation. Acute chest pain is an uncommon manifestation of foreign body aspiration and one that may be overlooked if history suggests another leading diagnosis. It is critical to avoid such a confounding bias, as anchoring can lead to adverse patient outcomes. CASE PRESENTATION: A 58-year-old man with diabetes mellitus, hypertension, coronary artery disease, and a history of substance abuse presented to the emergency department (ED) complaining of chest pain. He described a mid-chest pain that started after consuming cocaine. The pain was non-radiating but associated with mild shortness of breath. In the ED, he was tachycardic, hypertensive, and with normal saturation at room air. His EKG showed sinus tachycardia, and the laboratory workup was unremarkable. Chest X-Ray (fig.1) showed a round metallic density over the left mid lung. Chest CT scan (fig.2 and 3) showed a hyperattenuating foreign body within the left mainstem bronchus. He underwent a bronchoscopy in the operating room, and a dime was retrieved from the left mainstem bronchus with forceps. He tolerated the procedure well with no complications or airway injury and discharged home in stable condition. DISCUSSION: Despite the unusual times we have been going through due to the COVID-19 pandemic, ischemic heart disease remained the leading cause of death in the United States during 2020(1). It is well established that the abuse of illicit substances such as cocaine could lead to myocardial ischemia and infarction (2). Thus, it is a top differential diagnosis when a patient arrives in the ED with chest pain after cocaine use.It is well documented how premature closure and anchoring bias could negatively impact clinical outcomes (3,4,5). Hence, a thorough history and differential diagnosis are paramount to guide the workup and management. Cases of foreign body aspiration in adults often happen in the setting of altered mental status (6) or acute intoxication where patients rarely recall further details leading to their onset of symptoms. Still, the typical presentation includes cough and dyspnea (7) rather than chest pain.In a case of patient-reported recent cocaine use with subsequent chest pain, anchoring to a cocaine-induced chest pain diagnosis is at first understandable. It was the chest pain diagnostic workup that included a chest x-ray that found the cause that was not initially suspected. CONCLUSIONS: We present an interesting case of a dime aspiration lodging the left mainstem bronchus, who presented with chest pain after consuming cocaine. The lack of classic respiratory symptoms and the recent intoxication could have led to anchoring bias where the foreign body aspiration might have been overlooked. REFERENCE #1: 1. Ahmad FB, Cisewski JA, Minino A et al. Provisional Mortality Data – United States, 2020. MMWR Morb Mortal Wkly Rep 2021;70:519-522. REFERENCE #2: 2. McCord J, Jneid H, Hollander JE et al. Management of Cocaine-associated chest pain and myocardial infarction. Circulation. 2008;117:1897–1907. REFERENCE #3: 3. Khadilkar, S.V., Khadilkar, S.S. Bias in Clinical Practice. J Obstet Gynecol India 2020. 70, 1–5. https://doi.org/10.1007/s13224-019-01304-5 4. Makary MA, Daniel M. Medical error – the third leading cause of death in the US BMJ 2016;353:I2139 doi:10.1136/bmj.i2139 5. Saposnik, G., Redelmeier, D., Ruff, C. et al. Cognitive biases associated with medical decisions: a systematic review. BMC medical informatics and decision making, 2016(1), 138. https://doi.org/10.1186/s12911-016-0377-16. Ozdemir et al. Foreign Body Aspiration in Adult. Eurasian J Pulmonol 2015;17: 29-34 7. Bajaj et al. Foreign Body aspiration. J Thorac Dis 2020. doi: 10.21037/jtd.2020.03.94 DISCLOSURES: No relevant relationships by Israel Acosta Sanchez, source=Web Respons No relevant relationships by Tirsa Ferrer Marrero, source=Web Response No relevant relationships by Ray Urban, source=Web Response