Anterior Chest Pain Research Articles

A Case of Subarachnoid Hemorrhage Due to Vertebral Artery Dissection Following Spontaneous Coronary Artery Dissection on the Same Day: A Clinical Image

A woman in her 60s with well-controlled dyslipidemia presented with anterior chest pain. The electrocardiogram, chest radiograph, and echocardiogram were unremarkable; however, cardiac enzymes levels were elevated. Coronary angiography performed after dual antiplatelet therapy revealed spontaneous coronary artery dissection (SCAD). On the same day, the patient complained of mild headache that was initially treated as migraine. Hours later, the patient reported severe headache, followed by a decline in consciousness. Computed tomography of the head showed subarachnoid hemorrhage, while the angiography revealed bilateral vertebral artery dissection. The ruptured right vertebral artery dissecting aneurysm was treated with coil embolization. Despite treatment, the patient died seven days later. Autopsy confirmed dissections of the coronary and vertebral arteries. Although SCAD is rare, it often coexists with extracoronary vascular abnormalities due to systemic arterial fragility. Therefore, consider cerebrovascular disorders and promptly implementing diagnostic and management strategies in patients with SCAD and headaches is necessary.

326. SPONTANEOUS OESOPHAGEAL PERFORATION TREATED WITH OESOPHAGEAL STENT

Abstract We present the case of a 66-year-old male with spontaneous oesophageal perforation treated with oesophageal stenting. This patient reports sudden onset severe anterior chest pain after coughing and haematemesis with a background medical history of Type II DM, ESRF on Haemodialysis, Hypertension, OSA and takes prophylactic Aspirin. Endoscopy reveals multiple areas of oesophageal perforation in the proximal, middle, and distal oesophagus as well as a haematoma extending the entire length of the oesophagus to the COJ. This was treated with insertion of a WallFlex™ Fully Covered Oesophageal Stent as the patient was unsuitable for surgery. The result was re-epithelialisation of the entire oesophagus and complete resolution of the perforation at the mid-oesophagus. Dutch physician Boerhaave first described spontaneous oesophageal perforation in 1724. Commonly, these were treated surgically with associated high morbidity and mortality. Advances in endoscopic and stent technology has given clinicians a greater armamentarium to treat patients especially in the frail end elderly population. These advances include choices such as stent covers, biodegradable and removable stents, and anti-reflux valves. Complications with oesophageal stents such as fistula formation, stent migration and retrosternal pain are often associated with the length of placement. The choice of a fully covered retrievable oesophageal stent in our case provided reconstitution of oesophageal lumen and minimisation of mediastinal sepsis. With the progress in stent technology, we believe there will be greater use of endoscopic oesophageal stenting for oesophageal perforations bridges the gap between operative and non-operative management.

Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report

BackgroundIntercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage.Case presentationA 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful.ConclusionWe report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

Laparoscopic repair for a recurrent epigastric incisional hernia following xiphoidectomy: A case report

Introduction: Xiphodynia is a rare musculoskeletal disorder characterized by epigastric or anterior chest pain, for which xiphoidectomy is considered as a definitive treatment. This procedure and its complications are not well researched, particularly within Australasian populations. We describe the novel laparoscopic incisional hernia repair from a xiphoidectomy complicated by recurrent epigastric hernias. Case Report: A 49-year-old female presented with chronic epigastric pain post-xiphoidectomy for xiphoidynia. The patient previously underwent open mesh repair for an incisional epigastric hernia, complicated by infection and subsequent removal of the mesh. A vacuum-assisted closure device was then utilized, followed by delayed primary closure. However, she experienced ongoing pain, a recurrent mass, and hypertrophic scarring, confirmed by abdominal computed tomography (CT) scan. Our laparoscopic approach involved a standard supine position with three ports and preperitoneal dissection similar to transabdominal preperitoneal (TAPP) hernia repair. The defect was 5 × 8 cm in size. A simple prolene mesh (9 × 12 cm) was secured with AsorbaTack and Glubran 2, followed by peritoneal closure with a 3/0 V-Loc suture. At two months follow-up, the patient had no evidence of recurrent hernia, no ongoing pain, and satisfactory wound healing. Conclusion: Laparoscopic surgical repair using a TAPP approach is a safe alternative to open repair of an incisional recurrent epigastric hernia post-xiphoidectomy.

Impact of misdiagnosis on the treatment and prognosis of acute aortic syndrome

Abstract Funding Acknowledgements None. Introduction Acute aortic syndrome (AAS) embraces a spectrum of pathologies with relatively low prevalence but associated with high mortality. The clinical presentation of AAS is highly variable and the differential diagnosis with other much more common diseases such as myocardial infarction (AMI) or pulmonary embolism (PE) is often difficult to achieve. AAS detection requires a high index of suspicion and the delay in diagnosis is associated with increased morbidity and mortality. Purpose The aim of this study is to characterize the diagnostic approach to AAS patients in the emergency department (ED) and to study the impact of the initial diagnostic suspicion on the treatment and prognosis of patients with AAS. Methods The "Aorta Code" is an inter-hospital and interdisciplinary care protocol for the management of patients with AAS in a 4-Hospital network. Patients with AAS were prospectively and consecutively collected from 2019 to 2022. The sample was classified into two groups according to whether the initial suspicion was AAA or another clinical entity. The diagnosis of AAS was established by computed tomography in all patients. Time, clinical, treatment and prognostic variables were analyzed. Results A total of 113 patients with AAS were included. Of them, only 38% (34) were initially suspected of having an AAS (Figure). AMI and PE were the initial diagnosis in 34% of patients (Figure). There were no significant differences in age, history of hypertension or other cardiovascular risk factors between the groups (table). Anterior chest pain was more frequent in the "AAS-suspicion" group. The diagnostic time delay was longer in patients with initial misdiagnosis (table). Patients with type A AAS with initial misdiagnosis underwent surgery in a lower proportion (table). Although the differences were not significant, patients with initial misdiagnosis had more postoperative complications and higher mortality. Conclusion It is essential to maintain a high index of diagnostic suspicion for AAS in the ED. Initial misdiagnosis is associated with a delayed diagnosis, delayed surgical treatment and a lower rate of surgery. In addition, although it is a small sample size, this group of patients had more postoperative complications and higher mortality.

Ayurvedic Management of Gastroesophageal Reflux Disease <i>(Urdhwag Amlapitta)</i> - A Case Report

Background: In this busy life, people hardly find time for themselves, giving rise to a sedentary lifestyle, one of the leading causes of lifestyle disorders in which Gastroesophageal Reflux Disease (GERD) is also included. GERD is a very common disease found in society. It not only affects the mental but also the social life of a person. GERD causes retrosternal burning, sour eructation and anterior precordial chest pain (non-radiating) associated with constipation and anorexia. In Ayurveda, it is correlated with Amlapitta, which is one among the forty Pitta Nanatamja Vikara. In Modern science, there is no sure treatment that cures the patient completely but antacids and symptomatic treatment can give temporary relief. In such cases, Ayurvedic management proved to be the best as it cures the disease from the base. Aim: To discover the efficacy of Ayurvedic management in GERD and improve the patient’s quality of life. Methods: It is a single case study of a 50-year-old male patient who presented with retrosternal burning, sour eructation, anterior precordial chest pain (non-radiating) associated with constipation and anorexia for 5 months. After thoroughly examining the patient, Shamana Chikitsa was started (Laghu Sutashekhar Rasa, Avipattikarachurna, Kanchan Pittashamak Yoga, Abhayarishta). This treatment was given for one month. Results: The successful outcome of Shamana Chikitsa was found to be very effective with symptomatic assessment carried out after one week, fifteen days, and one month, respectively and the overall quality of life of the patient was significantly improved.

The Role of CT Imaging in a Fractured Coronary Stent with Pseudoaneurysm Formation.

We report a case of a 63-year-old male patient with multiple cardiovascular risk factors and previous myocardial infarction who was referred to the emergency department on September 2023 with symptoms and clinical and biological data consistent with an acute coronary event. A coronary angiography revealed severe ostial stenosis of the left anterior descending artery (LAD) and intrastent thrombotic occlusion in the first two segments of the LAD. Two drug-eluting stents were implanted and the patient was discharged when hemodynamically stable; however, three weeks later, he returned to the emergency department complaining of fever, anterior chest pain, dyspnea at rest, and high blood pressure values at home. High levels of troponin T, C-reactive protein, and NT-proBNP were detected and blood cultures showed methicillin-resistant Staphylococcus aureus. The computed tomography (CT) examination showed a saccular dilatation had developed between two fragments of a stent mounted at the level of the LAD, surrounded by a hematic pericardial accumulation. LAD pseudoaneurysm ablation and a double aortocoronary bypass with inverted saphenous vein autograft were performed and the patient showed a favorable postoperative evolution. In this case, surgical revascularization was proven to be the appropriate treatment strategy, demonstrating the need to choose an individualized therapeutic option depending on case-specific factors.

Concurrent spontaneous coronary dissection and reversible cerebral vasoconstriction syndrome during postnatal care.

Pregnancy-associated spontaneous coronary artery dissection (SCAD) and reversible cerebral vasoconstriction syndrome (RCVS) are rare conditions that may occur during pregnancy and the postpartum period. The coexistence of both diseases may pose a risk to patients, potentially resulting in a variety of complications and clinical manifestations. This is considered the first case of a patient who successfully recovered from a critical condition in the postpartum period, with contemporaneous SCAD and RCVS. A 33-year-old female with no known medical history was referred to the emergency department after experiencing cardiac arrest, which occurred 1 week after giving birth to her third child. She complained of sudden anterior squeezing chest pain, accompanied by a headache, and eventually collapsed due to ventricular fibrillation with seizure. She was successfully resuscitated after receiving basic life support. She showed an alert mentality and did not experience any further seizure events or additional neurological symptoms. Although vital sign remained stable, the level of highly sensitive troponin I was significantly elevated. Electrocardiography revealed sinus rhythm with T-wave inversion at V1-4, while chest computed tomography (CT) demonstrated severe aspiration pneumonia. The patient was admitted to the intensive care unit due to a high requirement of O2 supply. A consultation with the neurologic department and a brain magnetic resonance angiography (MRA) were conducted for the thunderclap headache. The brain MRA demonstrated stenosis in the basilar artery, the right M2 segment, and bilateral A1 segments, along with sulcal hyperintensity on post-contrast fluid-attenuated inversion recovery (FLAIR) suggesting blood-brain barrier breakdown due to vasoconstriction. Formal echocardiography showed regional wall motion abnormality in the left anterior descending artery (LAD) territory. After the improvement of pneumonia, a coronary angiography was performed, revealing diffuse luminal narrowing from the mid to distal LAD due to a long segmental, extensive dissection. We decided to maintain the medical therapy. A follow-up coronary CT angiography performed 6months later revealed complete remission of the dissected coronary vessel, and a brain MRA checked 3months later showed resolved vasoconstriction of the relevant cerebral vessels. The physicians must be aware of pregnancy-associated complications in certain patients. Clear diagnoses and proper treatments are required in pregnant patients who may be exposed to multiple acute conditions, in order to reduce complications and achieve favorable outcomes.

Isolated coronary artery ectasia presenting as inferior-posterior STEMI—a case-based state-of-the-art review of the current literature

Abstract Background This review is based on the case of a 71-year-old female patient, with cardiovascular risk factors, who was referred for emergency cardiological evaluation after experiencing severe anterior chest pain that had lasted for more than 5 hours at the time of admission. A diagnosis of inferior-posterior ST-segment elevation myocardial infarction was established, and emergency coronary angiography was performed. It revealed severe, diffuse dilation of the entire arterial coronary tree with slow flow and the presence of a large quantity of thrombotic material in the right coronary artery. Thromboaspiration was deemed unfit since the operator believed that there was a high risk of distal embolization with subsequent no-reflow, when passing with the catheter. As such, the patient started receiving anticoagulant therapy, and after one month she was scheduled for a control angiogram. The follow-up coronary angiography identified complete dissolution of the thrombus from the right coronary artery and a moderate stenosis in the distal segment, so no stent implantation was required. Rationale for review After performing a complete and comprehensive differential diagnosis, presence of isolated coronary artery ectasia was established. Coronary artery ectasia is a rare disease, usually found incidentally during coronary angiograms performed for other indications (chronic and acute coronary syndromes) with a vast etiology and complex pathophysiology. Because there are common morphopathologic pathways between coronary artery ectasia and atherosclerotic coronary artery disease, the clinical presentation of the former might have similar characteristics with the latter, but the management and prognosis of these patients is much less studied compared to the patients suffering from different phenotypes of coronary atherosclerosis. This review aims to summarize the etiopathogenesis, clinical presentation, diagnostic modalities, and different management pathways of coronary artery ectasia.

Mitral Valve Prolapse, Not Always an Easy Diagnosis

Abstract We present the case of a 61-year-old male patient, with no medical history, who was presenting for an anterior chest pain, which appeared suddenly during an effort, accompanied by palpitations, fatigue and dyspnea Physical examination revealed the presence of a 4/6 systolic murmur with maximal auscultation at the apex and radiation in the left axilla. Echocardiographic evaluation revealed diagnostically suggestive elements for severe posterior mitral valve prolapse without any rupture, color Doppler showing severe mitral regurgitation, a tricuspid valve prolapse, tricuspid regurgitation grade III and pulmonary hypertension. Coronary angiography revealed coronary arteries without hemodynamically significant lesions, and Holter ECG/24-hour monitoring detected atrial fibrillation in 44% of the monitoring time. In this context, the possible causes of the anterior chest pain were: microvascular angina, traction on the chordae or pulmonary hypertension. The patient had a surgical indication for mitral valve replacement or reconstruction. The department of cardiac surgery undergoes mitral valve replacement with a mechanical prosthesis with a favorable outcome.

Imaging of Osteoarticular Lesions in SAPHO Syndrome: A Case Report

Introduction: Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is an acronym for a variety of osteoarticular and dermatologic manifestations. Although the incidence and prevalence are probably underestimated, the syndrome is considered rare. Observation: A 45-year-old female patient, without any particular pathological history, presented with anterior chest pain, spinal pain and palmar pustulosis. The symptoms had been evolving for six months, in a context of apyrexia and conservation of the general state. The diagnosis of SAPHO syndrome was retained in view of the young age, the clinical presentation and the axial osteoarticular involvement on imaging. In addition, bone scintigraphy objectified the "bull's head sign". Discussion: The osteoarticular manifestations of SAPHO syndrome are characterized by osteosclerosis, hyperostosis, erosions, synovitis and synostosis. Some locations, especially the anterior chest wall, and some topographical associations are very suggestive. Clinical symptoms are non-specific, hence the interest of imaging. CT is the modality of choice to determine the extent of osteoarticular lesions. Magnetic resonance imaging has an important place. It allows to establish a correlation between the stage of the disease and the clinical symptoms. Conclusion: Knowledge of clinical manifestations and radiological features allows for early diagnosis and prevention of osteoarticular progression.

Multiple pulmonary masses with diffuse cystic lesions

A 50-year-old female patient, presenting with a past history of Reynaud's syndrome, xerostomia and xerophthalmia, was admitted to Fujian Provincial Hospital because of coughing for 10 days and left anterior chest pain for 1 day. Chest imaging showed multiple nodules and masses, and diffuse cystic lesions in both lungs. Based on the differential diagnosis of multiple pulmonary masses and diffuse cystic lesions respectively, autoantibodies, radionuclide dynamic imaging of the parotid, positron emission tomography-CT, CT-guided percutaneous transthoracic needle biopsy, and other examinations were performed. The diagnosis of diffuse large B-cell lymphoma stage ⅣA (lung, parotid gland) and Sjögren's syndrome was confirmed. By analyzing the imaging features and pathogenesis in detail, the diffuse cystic lesions of both lungs were considered to be related to lymphocytic interstitial pneumonia caused by Sjögren's syndrome. The pulmonary space-occupying lesions in the lungs were significantly absorbed after RCHOP regimen for lymphoma.

Fracture of the Costal Cartilage A Misdiagnosed Pathology: about A Case and Literature Review

Costal cartilage fracture is a rare traumatic injury but the frequency is probably underestimated. This lesion, not visible on X-rays, is nevertheless simple diagnosis in ultrasound, computed tomography and MRI. We report here a case of low anterior anterior post-traumatic chest pain following a brawl in a young patient in general condition.

1154 MYOCARDIAL INFARCTION IN A TRANSGENDER FEMALE UNDERGOING HORMONE THERAPY: THE IMPACT PROLONGED EXPOSURE TO HORMONE THERAPY

Abstract Background Gender Identity (GI) is defined by a complex interplay between biological, psychological, environmental, and cultural factors. Health care services provide counseling, hormone treatment, and gender-affirming surgery. Testosterone is used for cross-sex hormone therapy in female-to-male transgender persons. Previous evidence suggests that testosterone administration is associated with hypertension, decreased high-density lipoprotein (HDL), increased low-density lipoprotein (LDL), and obesity, thus increasing cardiovascular risk. Hereafter, we report the case of a patient female-to-male on testosterone therapy undergoing percutaneous coronary intervention (PCI) and stent implantation for acute myocardial infarction. Case Description A 44-year-old Italian transgender (female-to-male) without common cardiovascular risk factors and family risk was admitted to the local emergency room with a sudden onset of anterior chest pain. The electrocardiogram showed anterior ST-Segment Elevation, and accordingly, the patient was transferred to our Institution for emergency coronary angiography. Past medical history revealed breast reduction, osteosynthesis of the right femur, hemorrhoidal pathology, and iron deficiency anemia. Of interest, drug history revealed a hormonal therapy with intramuscular testosterone undecanoate over the from 2005 for gender conversion (250 mg every 3 weeks) and Tamoxifen 20 mg/die from 2006. The coronary angiography performed after 90 minutes to the symptom onset revealed a total occlusion of the proximal left anterior descending artery (LAD) and minimal atherosclerosis of the remaining vessels. Recanalization of the LAD was achieved by pre-dilatations with a 2.5×15mm balloon catheter, showing diffuse atherosclerosis of the middle and distal LAD involving the origin of a diagonal branch (Medina 1,1,1). Then the lesion was treated with the implantation of three drug-eluting stents in overlap, followed by POBA (Plain Old Balloon Angioplast) of the diagonal branch with a 2.5×12 mm balloon at the ostium (Final TIMI flow III). The patient was then moved to the intensive care unit. Laboratory tests showed an altered lipid panel (overall cholesterol 210 mg/dl and LDL-cholesterol 153 mg/dl), elevated levels of cardiac enzymes (CK-MB 92.5 ng/ml, myoglobin 1606 ng/ml, TnT hs 1014 ng/L and NTproBNP 1263 pg/ml) and anaemia (Hb 9,1 mg/dl). The echocardiogram revealed akinesia of the apex with thrombotic formation (2.0×1.0 mm) and mid-distal anterior wall, with a 40% ejection fraction. Accordingly, parenteral anticoagulant was started. No further complications were observed the day after the procedure, with a progressive reduction of the miocardionecrosis enzymes and thrombotic formation. Ten days after, at the resolution of the thrombotic formation, the patient was discharged. Discussion This case report highlights the importance of primary prevention in patients undergoing long-term testosterone therapy for gender conversion, regardless of age and risk factors. For instance, prior evidence about the risk of recurrent ischemic events in these high-risk patients is poor with a high heterogeneity across the studies. Accordingly, high quality prospective and multicentric studies are needed to assess if there is a correlation between hormonal therapy for gender conversion and cardiovascular disease.

P15 Acupuncture treatment of Costochondritis, a case series

Introduction/BackgroundI had been practising acupuncture for 30 years and noticed while working in the rheumatology clinic that costochondritis had a particular response to acupuncture. As this condition is extremely debilitating and often misdiagnosed, a case series of 8 cases is presented, the majority of whom were seen in primary care.Description/MethodCostochondritis is characterised by anterior chest pain associated with painful tender costochondral (CC) joints felt on palpation. These mainly affect the 2nd to 5th costochondral junctions, either unilateral or bilateral. Other areas of the anterior and lateral chest wall can also be affected. The pain is often severe and nocturnal, of sudden onset and can be associated with shock, nausea and dyspnoea, causing patients to call for an ambulance. Tietze's syndrome is a rare variant of this, usually affecting younger patients.Patients with persistent chest wall pain were offered acupuncture. Details of age, duration of symptoms, number of treatments and VAS pain scores were recorded day and night, (Table 1) pre and post treatment Patients with thoracic pain were excluded.0.25*25mm and 0.25*30mm needles were used with silicon tips and a guide tube, to help prevent painful insertion. An infra-red lamp (Bio-lamp) was used + electro-acupuncture (EA) if insufficient improvement after two close treatments, sessions were continued weekly.Acupuncture points used were local tender/trigger points + distal Chinese points P6 and LI4. Other points used were CV 17, GB 34, SI6, GB39 or Sp 6 and St36. An average of 4.7 sessions were needed.Audit of Acupuncture Treatment Table 1P15 Table 1PATIENTAGEDURATION OFNUMBER OFVAS INITIAL (0-10)VAS FINALYEARSPROBLEMTREATMENTSDAYNIGHTDAYNIGHT1375 MTHS410100022618 MTHS8 (1 EA)5.57.5023653 WEEKS5 (+EA)79114584 DAYS4972256210 WEEKS7 (+EA)68026346 WEEKS447227289 MTHS314008255 YEARS38700Recurrence of pain3651 WEEK4 (+EA)88126345 WEEKS228227282 WEEKS11311Six patients took daily analgesia which was rapidly reduced to nil. All completed their treatment until their pain stabilised. There were no adverse events.Average improvement in the day was 89% and night 85%. Recurrences of pain improved by 11% in the day and 72% at night. The attacks of severe chest pain and dyspnoea stopped, abating anxiety.Discussion/ResultsCostochondritis is a highly debilitating condition and I had noticed that acupuncture could be a dramatic treatment for this[i]. It can affect up to a third of patients attending emergency departments with atypical chest pain[ii] and 1-3% of patients in primary care[iii].It seems to be a missed diagnosis by Accident and Emergency (A&E) doctors and GPs, perhaps because the chest wall was not carefully palpated. One patient had ankylosing spondylitis (AS) and another had systemic lupus erythematosus but attributed her pain to prolonged laughter. Five patients attended cardiology clinics including one who had a coronary angiogram. Another had tests for upper abdominal pain which also were normal.All the patients were female although quoted F:M ratio is 7:3Differential diagnoses include: acute coronary syndromes, lung problems, trauma, upper gastroenterology pathology or neoplasiaPathogenesis is unclear but the onset can be acute and follow:Respiratory tract infection Extreme sneezing, coughing or laughterChest wall trauma Micro trauma from costovertebral dysfunctionFibromyalgia Inflammation from inflammatory joint disease.[i] Alexander R; White A. Acupuncture in a Rheumatology Clinic. Acupuncture in Medicine; Dec 2000 vol.18 (no.2): 100-103[ii] Disla E; Rhim HR; Reddy A; Karten I; Taranta A. A prospective analysis in an emergency department setting. Arch Intern Med. 1994; 154(21):2466-2469[iii] Ayloo A; Cvengros T; Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care (Review) Dec 2013 40(4): 863-87Key learning points/ConclusionNormal management of costochondritis includes analgesia, physiotherapy, steroid injections and occasionally surgery[i]. 30% can have protracted pain. There are isolated reports of acupuncture for this condition, integrated with conventional medicine[ii] [iii]. Acupuncture also has been used for myofascial trigger points including costochondritis[iv].Acupuncture is now an accepted modality of pain management and in 2021 was recommended in NICE guidelines for the treatment of Chronic Primary Pain alongside exercise programmes and CBT ahead of analgesic medication[v]. It has also been recommended in the management of low back pain in patients aged 60 years and over as a non-drug treatment[vi].This paper highlights the fact that acupuncture appears to be a safe effective treatment for costochondritis, with further research and more access needed for this therapeutic modality.Increased awareness of this condition would make complex invasive investigations less necessary.[i] Gologorsky R; Hornik B; Velotta J. Surgical Management of Medically Refractory Tietze's Syndrome. Annals of Thoracic Surgery; Dec 2017; vol. 104 (no. 6)[ii] Jonkman FAM.; Jonkman-Buidin M.L; Stolwijk P.W.J. Surprise after successful treatment of a patient with noncardiac chest pain using acupuncture. Medical Acupuncture; Feb 2015; vol.27(no 1):83-90[iii] Lin, Katerina; Tung, Cynthia. Integrating Acupuncture for the Management of Costochondritis in Adolescents. Medical Acupuncture; Oct 2017; vol.29(no 5): 327-330[iv] Baldry P. Cardiac and non-cardiac chest wall pain. Acupuncture in Medicine;1997; vol.15(no.2): 42-45[v] NICE guideline; Chronic Pain (primary and secondary) in over 16s (NG 193 April 2021)[vi] Traeger A; Underwood M;Ivers R; Buchbinder R. Low back pain in people aged 60 years and over. BMJ 2022 vol. 376: e066928

A spontaneous reduction in tumor size of a thymic carcinoma: a case report

BackgroundSpontaneous regression of thymic carcinoma is extremely rare. We report a case of a resected thymic carcinoma with preoperative spontaneous regression in a 67-year-old woman.Case presentationThe patient presented with low-grade fever and anterior chest pain. Chest computed tomography (CT) showed a 55 × 43 mm exophytic heterogeneously enhancing mass showing some areas of necrosis. Chest CT done one day preoperatively revealed that the tumor had rapidly shrunk for one month. Surgical resection was performed to obtain a definitive diagnosis and achieve complete resection, yielding a postoperative diagnosis of thymic carcinoma. The patient survived without signs of recurrence for 12 months postoperatively.ConclusionsMediastinal tumors with necrosis demonstrating spontaneous regression should include thymic carcinomas in the differential diagnosis.

Identification of a novel FGFR2-KIAA1217 fusion in esophageal gastrointestinal stromal tumours: A case report

BackgroundGastrointestinal stromal tumours (GISTs) rarely arise in the esophagus. The clinical course and treatment options for esophageal GISTs are poorly understood because of their rarity. In general, the mutation spectrum of esophageal GISTs resembles that of gastric GISTs. Wild-type (WT) GISTs lacking KIT and PDGFRA gene mutations occasionally occur in adults; primary esophageal GISTs are commonly WT.Case presentationHerein, we report the case of a 41-year-old female patient who presented with a 1-week history of anterior upper chest pain. Chest computed tomography revealed a 3.7 cm × 2.8 cm × 6.7 cm soft tissue mass in the right posterior mediastinum adjacent to the esophagus. The patient underwent thoracoscopic mediastinal tumor resection and was subsequently diagnosed with an esophageal GIST. Neither KIT nor PDGFRA mutations were detected by Sanger sequencing; however, next-generation sequencing (NGS) identified an FGFR2-KIAA1217 gene fusion in the tumor tissue. No relapse was observed in this patient during the 8-month treatment-free follow-up period.ConclusionTo the best of our knowledge, this report is the first to describe an FGFR2-KIAA1217 fusion in a patient with a quadruple WT esophageal GIST. When WT KIT/PDGFRA GISTS are suspected, intensive genetic analysis is recommended, and obtaining a better molecular characterization of these tumours might reveal novel therapeutic avenues.

Is interventional bronchoscopy the first-line solution for mediastinal compression syndrome?

Abstract The mediastinum is known as the anatomical structure connecting the two pleural sacs. A variety of anatomical structures, from organs to veins and arteries, make mediastinal pathology extremely adventurous. We submit the case of a 67-year-old female patient, a former smoker, who presented to our clinic with dyspnoea on slight exertion, anterior chest pain and ineffective cough. The alarming aspect of the case is the stridor present at regular intervals and the patient’s dependence on oxygen. The CT scan reveals a compression syndrome caused by a tumour located in the upper and middle mediastinum that encompasses mediastinal venous and arterial structures and exerts an extrinsic stress effect on the oesophagus and tracheal. An emergency fibrobronchoscopy is performed and it is placed on a Y-shaped tracheal stent; additionally, two biopsies are also taken from different places. The point of debate of the case was related to the coexistence of two simultaneous histopathological types. The medical team’s swift intervention has given this patient a fighting chance to continue oncological and radiotherapy treatment.

Successful treatment of relapsing polychondritis with circumferential bronchial wall thickening including the tracheomembranous area with tumor necrosis factor-α inhibitor.

This is a case of a 55-year-old man who presented with cough and anterior chest pain. Tracheal biopsy confirmed the diagnosis of relapsing polychondritis (RP). Although the patient had circumferential bronchial wall thickening extending to the tracheomembranous area and was positive foRPR3-ANCA, he did not meet the diagnostic criteria for granulomatosis with polyangiitis. The patient was refractory to prednisolone + methotrexate + azathioprine and responded to adalimumab, a biologic tumor necrosis factor-α inhibitor effective in RP refractory cases. Herein, we report a rare case of RP with circumferential bronchial wall thickening extending to the tracheomembranous area.

Kawasaki Disease Undiagnosed in Childhood, Myocardial Infarction in Adulthood - Case Report

Abstract Kawasaki disease is a vasculitis, usually diagnosed in childhood, for which reason treatment should be started as early as possible, to avoid complications. We present the case of a 37-year-old man with anterior chest pain, with coronary character, without known cardiovascular risk factors, and who, following investigations, is directed to emergency angio-coronarography due to acute coronary syndrome. Here, we highlight the characteristic coronary dilations for Kawasaki disease. It is released in very good general condition, with proper treatment.