Anterior Chest Pain Research Articles

Shoulder Pain-Basketball

HISTORY: 16 year-old male multi-sport athlete developed left shoulder and anterior chest pain while weight lifting in the off season. Initial shoulder and pectoralis evaluation was unremarkable. He initiated PT with limited improvement and subsequently discontinued his participation in sports. His pain was suggested to be chronic and exacerbated with running, sneezing and movement of neck and shoulders. Due to ongoing symptoms and lack of diagnosis, a second opinion was sought at our institution. PHYSICAL EXAMINATION: Well appearing with age appropriate development. No significant atrophy, swelling or deformity of the left shoulder or spine. Midline tenderness to palpation T1-T3. No tenderness to palpation of the anterior chest wall. Limited neck flexion, otherwise neck and left shoulder ROM were full and pain free. Bilateral upper extremities had full and symmetric muscle strength and physiologic reflexes. Minimal pain with left empty can/full can provocative testing. DIFFERENTIAL DIAGNOSIS: Rotator cuff tendinopathy, Pectoralis strain, Brachial Plexopathy, Mechanical back pain, Neoplasm TESTS AND RESULTS: MRI chest: lobulated enhancing mass T2 vertebral body with soft tissue infiltration of the left T1-3 neuroforamen and involvement of the epidural space with mass effect on the spinal cord. CT guided biopsy: bone forming neoplasm FINAL WORKING DIAGNOSIS: Aggressive Osteoblastoma TREATMENT AND OUTCOMES: Shoulder pain was referred from central neoplastic process and pediatric oncology and orthopedic surgery consulted. Surgical resection pursued with pre-operative transarterial embolization. Stage 1: anterior T2 vertebrectomy with placement of expandable cage. Stage 2: posterior epidural tumor removal, decompression and instrumented fusion C7-T5. Final surgical pathology osteoblastoma. PM&R consulted and patient worked with PT and OT during acute hospital stay. Rapidly progressed from mod-max to min assistance for ADL/IADLs and functional mobility. Discharged post-op day 7 with home exercise program for left upper extremity incoordination. Stable 3 week post-op visit, will start formal OT upon returning home.

Total Proximal Left Anterior Descending Artery Occlusion Presenting as Right Sided Chest Pain with a Misdiagnosis of Costochondritis: A Case Report

Background Acute coronary syndrome refers to a group of clinical symptoms consistent with acute myocardial ischemia or infarction that are potentially life threating requiring immediate interventions. Certain proportion of patients can present with atypical symptoms leading to a missed diagnosis associated with devastating outcomes. Case presentation We present a 60 years’ female of African descent with a medical history of hypertension and type 2 Diabetes mellitus who presented with a 2 months’ history of right-sided anterior chest pain and was diagnosed with costochondritis. Further assessment revealed, normal cardiac markers and an electrocardiogram suggestive of anterior wall myocardial infarction. A coronary computed tomography and cardiac magnetic imaging scans revealed a total occlusion of the proximal left anterior descending artery and a viable myocardium respectively. She underwent successful percutaneous coronary interventions with stenting with complete alleviation of her chest pain. Conclusions This case report highlights the importance of having a high index of suspicion in high-risk groups such as older females with co-morbidities presenting with atypical symptoms suggestive of acute coronary syndrome to health care providers. This ensures early diagnosis and provision of appropriate treatment associated with good outcomes. Likewise, the case also advocates on the use of advanced cardiac imaging in patients with inconclusive electrocardiographic and biochemical tests.

A rare case of combined thymoma and a multilocular thymic cyst discovered due to chest pain

BackgroundA thymoma with chest pain and multilocular thymic cysts (MTCs) is very rare.Case presentationA 49-year-old man presented to another hospital complaining of an anterior chest pain. Chest computed tomography (CT) showed an anterior mediastinal tumor 60 × 30 × 55 mm in size. The boundary with the pericardium or left brachiocephalic vein seemed to be partially unclear while enhanced by the contrast medium, and so the tumor could have invaded them. No definitive diagnosis of myasthenia gravis was made although the serum anti-acetylcholine receptor antibody count was high. We performed an extended thymectomy with combined partial resection of left brachiocephalic vein, left upper lobe, and left phrenic nerve. He was discharged with no chest pain and no complications post-surgery. The tumor was pathologically type B2 thymoma with hemorrhage necrosis and MTCs, and we diagnosed Masaoka stage II because of no histological infiltration to the organs.Conclusions We speculated that hemorrhagic necrosis due to infarction in tumor caused the inflammation to spread to the surrounding organs, which was related to the chest pain and the development of MTCs.

Physical Therapy Evaluation and Treatment for Noncardiac Chest Pain: A Case Report

Background Most chest pain in athletes is categorized as musculoskeletal and not cardiovascular in nature; however, differential diagnosis is challenging for providers across all disciplines. The deleterious impact resulting from clinical error in either diagnosis or management could result in irreversible negative medical outcomes. Some patients' symptoms resolve with activity modification and/or medication, which is considered standard medical management. Other patients have pain and activity restrictions for protracted periods. However, physical therapy is often not prescribed. Case Presentation A 32-year-old man presented with a 4-month history of isolated anterior chest pain that did not resolve with rest or medication. He was treated with manual physical therapy and targeted exercises in a progressive manner over 4 clinical visits. Outcome and Follow-Up The patient demonstrated clinically meaningful improvement in pain on the numeric pain-rating scale and in function on the global rating of change scale, allowing him to return to unrestricted physical training. Discussion Sound clinical reasoning, paired with systematic manual clinical assessment and treatment, facilitated the return to prior level of function for this patient with noncardiac chest pain. JOSPT Cases 2021;1(2):101–106. doi:10.2519/josptcases.2021.10186

Invasive Chest Wall Tumor in an Active-Duty Marine

A 23-year-old active-duty Marine presented to a physical therapy clinic with a 3-month history of right-side anterior chest pain without specific injury. Initial radiographs taken by his primary care physician were noncontributory and were followed by a diagnostic ultrasound exam, which showed a partial-thickness tear of the pectoralis major. Orthopaedic surgeon evaluation 1 month later noted differential diagnoses of a partial pectoralis tear and a soft tissue mass. Magnetic resonance imaging (MRI) was ordered to differentiate the lesion but was delayed 1 month. As a result, the diagnosis remained a partial right pectoralis tear until the MRI was completed, revealing an invasive tumor along the right chest wall. JOSPT Cases 2021;1(2):107–108. doi:10.2519/josptcases.2021.10148

Acute Aortic Dissection in Third Trimester Pregnancy with Well Controlled Hypertension

We describe a 32-year-old pregnant woman at 31 + 6 weeks of gestation who presented to a tertiary-care hospital with headache and back pain. She was found to have a sign of tear about 1.3 cm away from the aortic valve, and the torn intima extended upward to the ascending aorta and the descending part of the aortic arch. She delivered a live male neonate via cesarean delivery. She had a history of hypertension with oral Labetalol 50 mg twice times daily. At the very beginning of the onset, physicians in the emergency room wouldn’t be aware of the symptoms of aortic dissections, as well as atypical presentations which include anterior chest pain or chest pain radiating to the back. She was only received anti-hypertension management, until her symptoms of back pain aggravated, and an aortic dissection was confirmed by ultrasound and CT angiography. Then she received a mechanical aortic valve replacement. After 51 days of treatment, she was discharged and recovered without any complications. Aortic dissection in pregnancy is a rare disease. We recommend transthoracic echocardiography every 1 to 2 months to monitor the diameter of the ascending aorta during pregnancy in which patients with hypertension problems or other risk factors of aneurysm and perform the CT angiography scan to confirm aortic dissection in a pregnant or postpartum woman with suspicious pain symptoms. It is essential that multidisciplinary approach in which teams must urgently collaborate to ensure the protection life of both mother and baby.

Recurrent Pneumothoraces in a Patient with Emery Dreifuss Syndrome: A Case Report and Review of the Literature.

Emery Dreifuss Muscular Dystrophy (EDMD) is an inherited disorder which leads to progressive worsening of muscular function. In this report, we present a case of a 29 years old woman with EDMD who presented with sudden left anterior chest pain and was diagnosed with recurrent pneumothoraces. We will highlight how a patient with EDMD-related pneumothoraces can develop rapidly worsening ventilatory function resulting in acute hypercapnic respiratory failure. Patients with muscular dystrophies require a high level of acuity on part of the physician to predict. Physician should be on high alert when treating patients with EDMD and pneumothorax given the potential for rapid respiratory deterioration and the requirements of immediate ventilation support. Having the ability to predict the severity of respiratory involvement in patients with EDMD is a key for favorable outcomes, besides prognostication, it also allows physicians to develop an earlier interventional plan for management of potential respiratory failure. In this report, we also provide in-depth review regarding the approach to the assessment of respiratory function in patients with EDMD and the current literature on the management of respiratory complications seen in patients with EDMD, a highly vulnerable population.

A case report of aortic root repair using a pericardial autograft for type A aortic dissection

BackgroundAcute type A aortic dissection with a dissection flap extending into the sinus segment often involves the commissures and the coronary ostia. In most cases, the intimal flap must be retained in order to restore aortic valve competence and reconstruct the coronary ostia. Residual dissection flap has the potential risks of proximal bleeding and adverse effects on long-term durability. We established a novel technique to reconstruct the aortic root using a pericardial autograft and significantly reduce remnant dissection tissues.Case presentationA 50-year-old female was admitted to our center with acute anterior chest pain and backache lasting about 10 h. Computed tomographic (CT) scans showed type A aortic dissection, with both coronary ostia being involved. Doppler echocardiography showed moderate aortic insufficiency. The dissection intimal flap was removed to the normal aorta wall near the annulus at the noncoronary sinus, leaving a 5 mm rim of intimal flap near the commissures and coronary ostia. Using a pericardial patch as a new aortic wall to reconstruct the root while preserving the aortic adventitia to fix and strengthen the new pericardial aortic wall. Ascending aorta and total arch replacement combined with frozen elephant trunk procedure was performed at the same time. The patient got an uneventful postoperative course.ConclusionAortic root repair with a pericardial autograft is a safe and effective technique to treat acute type A dissection involving the sinus. Using this technique, residual dissection tissues could be significantly reduced, which subsequently decreases the risk of proximal bleeding and hence increases long-term durability.

PNEUMOMEDIASTINUM IN PATIENTS WITH SUBSTANCE ABUSE: A CASE SERIES

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumomediastinum (PM) is the presence of air in the mediastinum. PM is associated with asthma exacerbation, severe cough or vomiting, and other activities associated with breathing maneuvers. Although the majority of cases could be managed conservatively, PM could be potentially fatal if it progresses to malignant PM, which requires thoracotomy or video-assisted thoracoscopy for management. Therefore closely monitoring the patient is necessary. CASE PRESENTATION: Case 1: A 20-year-old male who uses marijuana, was admitted due to 3 days of intractable nausea, vomiting, and right-side anterior pleuritic chest pain. Vital signs were normal. Abdominal exam showed epigastric tenderness, without guarding or rebound. Laboratory showed leukocytosis. CXR revealed subcutaneous emphysema in the left supraclavicular region without PM. Chest CT showed free air in posterior mediastinum (Figure 1). Evaluation did not demonstrate esophageal rupture. He was treated conservatively. The symptoms improved and he was discharged. Case 2: A 20-year-old male with marijuana use for 4 years presented with shortness of breath, intractable vomiting, bloody emesis, chest pain, and shortness of breath. Vital signs were normal. Examination showed subcutaneous emphysema along anterior chest up to neck, with clear and equal breath sound. Laboratory showed leukocytosis. CXR and chest CT showed subcutaneous emphysema and PM (Figure 2). With investigation, there was no evidence of esophageal rupture. The symptoms resolved and he was discharged. Case 3: An 18-year-old male with type 1 diabetes mellitus and polysubstance abuse history presented with sudden severe right-side chest pain, mild shortness of breath, and nausea over 2 days. He admitted smoking methamphetamine prior to his symptoms. Vital signs were normal. Examination was notable for moderate dehydration. Laboratory revealed leukocytosis, elevated blood glucose, and wide-anion gap metabolic acidosis with elevated acetone. Urine drug screen was positive for methamphetamine. CXR showed PM and left supraclavicular subcutaneous emphysema. Chest CT showed isolated PM (Figure 3). The patient was given pain medication and was treated for DKA. He improved and was discharged. DISCUSSION: PM among substance users is believed to be a result from barotrauma during breathing maneuvers. An increase in alveolar pressure with development of a pressure gradient between alveoli and surrounding blood vessels leads to increased alveolar pressure, rupture of the alveolar septa, collapse of the adjacent vascular structures, and air dissection around the peribronchial and perivascular sheaths. Conservative management is sufficient for the majority of PM. CONCLUSIONS: Pneumomediastinum is a rare condition that could be potentially life threatening. PM should be considered in patients with history of inhaled drug use who develop sudden chest pain. Reference #1: Kouritas VK, Papagiannopoulos K, Lazaridis G, et al. Pneumomediastinum. J Thorac Dis 2015;7(Suppl 1):S44–S49. Reference #2: Weiss ZF, Gore S, Foderaro A. Pneumomediastinum in marijuana users: a retrospective review of 14 cases. BMJ Open Respir Res. 2019 Feb 12;6(1):e000391. doi: 10.1136/bmjresp-2018-000391. Reference #3: Miller WE, Spiekerman RE, Hepper NG. . Pneumomediastinum resulting from performing Valsalva maneuvers during marijuana smoking. Chest. 1972 Aug;62(2):233-4. DISCLOSURES: No relevant relationships by Amr Ismail, source=Web Response No relevant relationships by Passisd Laoveeravat, source=Web Response No relevant relationships by Arunee Motes, source=Web Response No relevant relationships by Victor Test, source=Web Response

5-FLUORACIL AS A CAUSE OF ACUTE CORONARY THROMBOSIS

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: 5-Fluorouracil (5-FU) is considered to be the backbone of colorectal cancer (CRC) systemic therapy since the great majority of recommended regimens include its administration. However, there are a few reports showing direct cardiac toxicity of the drug due to direct heart injury or less common coronary thrombosis. We report a patient with known stable CAD and new episode of chest pain after 5-FU injection for CRC treatment. CASE PRESENTATION: This is a 51-year-old man with a past medical history significant for CAD with previous coronary bypass surgery and CRC in chemotherapy with 5-FU who presented at emergency department with chest discomfort. He had his outpatient chemotherapy and minutes after the infusion of the drug patient developed anterior chest pain, sharp, associated with nausea and vomiting. Initial troponins were positive, but ECG did not show any signs of acute ischemia. Because of hypoxia and low blood pressure, patient was intubated and sent to the intensive care unit. Echocardiogram showed reduced ejection fraction with wall motion abnormalities. Patient performed a left heart catheterization which showed an acute occluded saphenous graft to marginal branch of the circumflex artery. A drug-eluting stent was placed and after 7 days of recovery, patient was discharged home. DISCUSSION: Chemotherapy toxicity with 5-FU is a rare phenomenon with sparse cases described in the literature. There are a few explanations for its toxicity including direct vasculature lesion and also diffuse, severe vasospasm of coronary arteries. It is more common in patients with previous coronary artery disease and it seems to be more dangerous when the medication is given in a bolus regimen instead of continuous infusion. CONCLUSIONS: Patients presenting with chest pain in use of 5-FU have a broad differential which includes direct cardiotoxicity caused by the drug and acute coronary syndrome. The correct diagnosis is crucial, and the first step should be discontinuation of the drug with an integrated approach involving critical care team, oncology, and cardiology. Reference #1: Abdel-Rahman O. 5-Fluorouracil-related Cardiotoxicity; Findings From Five Randomized Studies of 5-Fluorouracil-based Regimens in Metastatic Colorectal Cancer. Clin Colorectal Cancer. 2019;18(1):58–63. Reference #2: Sara JD, Kaur J, Khodadadi R, Rehman M, Lobo R, Chakrabarti S, et al. 5-Fluorouracil and Cardiotoxicity: a Review. Ther Adv Med Oncol. 2018;10. Reference #3: Polk A, Vistisen K, Vaage-Nilsen M, Nielsen DL. A systematic review of the pathophysiology of 5-fluorouracil-induced cardiotoxicity. BMC Pharmacol Toxicol. 2014;15(1):1–11. DISCLOSURES: No relevant relationships by Susan Bannon, source=Web Response No relevant relationships by Ricardo De Castro, source=Web Response No relevant relationships by Michelle Helbig, source=Web Response No relevant relationships by Neiberg de Alcantara Lima, source=Web Response No relevant relationships by Aditya Mehta, source=Web Response

The Diagnosis and Treatment of Adult Patients with SAPHO Syndrome: Controversies Revealed in a Multidisciplinary International Survey of Physicians

IntroductionThis study aimed to investigate the current practice in the diagnosis and treatment of SAPHO syndrome among the international rheumatology and dermatology communities.MethodsWe conducted an electronic survey among the members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), the Japan Spondyloarthritis, and Israeli Societies of Rheumatology.ResultsA total of 78 physicians participated in the survey: rheumatologists (83%, n = 65), dermatologists (11.5%, n = 9), and orthopedics (3.8%, n = 3). SAPHO was considered a subtype of spondyloarthritis by 48.7% (n = 38), a subtype of psoriatic arthritis by 19.2% (n = 15), a separate entity by 25.6% (n = 20), and a subtype of reactive arthritis by 6.4% (n = 5). Palmoplantar pustulosis was the most prevalent cutaneous manifestation (n = 44, 56.4%) and anterior chest pain—the most prevalent osteoarticular manifestation (n = 66, 84.6%). The majority (84.6%, n = 66) voted for the update of the present diagnostic criteria by Khan 1994. Magnetic resonance imaging was considered the preferred imaging modality for the diagnosis of SAPHO by 41% (n = 32). Conduction of bone biopsy for diagnosis of non-infectious osteitis was supported only by 10.3% (n = 8). Patient-reported outcomes were considered the most appropriate measure for the assessment of disease activity by 47.4% (n = 37). The treatment approach was overall similar among the rheumatology and dermatology communities, including non-steroidal anti-inflammatory drugs, bisphosphonates, conventional disease-modifying anti-inflammatory drugs, and biologics.ConclusionsOur study underlines the controversy on diagnosis and treatment of SAPHO syndrome among specialists in rheumatology and dermatology and emphasizes an unmet need for update and validation of diagnostic criteria and treatment approach.

Acute thoracic aortic dissection: a case report

Introduction: Aortic dissection (AD) is the most common aortic emergency, result in a catastrophic outcome. Patients usually asymptomatic, some of them present with sudden severe, tearing or sharp back or anterior chest pain and haemodynamic disturbance. Early and accurate diagnosis and treatment determine the patient outcome.Case Report: A case of 40 years old man complained of acute, sharp, chest pain since 4 days before admission which worsen instead of medical treatment, with a history of smoking since a few years ago. A vital sign was within normal limit. Laboratory result showed high CKMB, troponin T, LDH result. Occasional ventricular extrasystoles and inferior ischaemic was found in the ECG examination. From echocardiography, the patient suspected to have aortic dissection Stanford type A since an intimal flap on ascending aorta was found, with left ventricle hypertrophy, dilatation of right atrium and right ventricle, severe aortic regurgitation, moderate mitral regurgitation, severe tricuspid regurgitation, moderate pulmonary regurgitation and moderate pulmonary hypertension. From plain radiography, the patient showed mediastinum widening and cardiomegaly, CT angiography showed Stanford type A aortic dissection (DeBakey type I). The patient refused to seek further treatment for operation as suggested.Conclusion: It is still challenging to differentiate aortic dissection (AD) and another acute chest emergency. Since clinical presentation and laboratory result may be similar between those illnesses. Therefore careful history taking and further imaging examination should be considered to increase the patient outcome.

Back And Shoulder Pain - Heavy Lifting

HISTORY: 52 year-old male presents with right (R) upper back pain and R anterior chest pain. Presented to Emergency Department (ED) for R scapular pain after pulling a piano 1 week ago. Clinically appreciated painful R scapular stabilizers without swelling or bony tenderness. Discharged with analgesia and muscle relaxant. Subsequently developed erythema at site and went to second ED. Clinically evaluated and discharged with opiate. Erythema progressed, and patient returned to ED. PHYSICAL EXAMINATION: Inspection with erythema extending into R lateral neck. Blanching and warm bilateral anterior chest wall. Tenderness on palpation greater on R than L including pectoralis origin, SC joint. No crepitus. Heart and lung sounds normal, painless chest excursion. R shoulder painful adduction with FROM. R scapula painful protraction and retraction. R AC joint painless scarf sign. Cervical spine, left shoulder, bilateral elbow without additional findings. DIFFERENTIAL DIAGNOSIS 1. Cellulitis/Necrotizing fasciitis 2. Thoracic outlet syndrome 3. Pectoralis myositis 4. Thrombophlebitis/DVT 5. Osteomyelitis/Septic joint TESTS AND RESULTS: Remarkable Labs - WBC 15.8 - CPK 68 - CRP 460 - ESR 108 - Alk Phos 253 Chest X-Ray - Paratracheal lymphadenopathy CT Chest with Contrast - Fluid collection with inflammatory changes midline between pectoralis major muscles without gas at the level of sternal notch and manubrium - Asymmetric soft tissue thickening in the R clavicular head, SC joint, and retrosternal region with fluid collections MRI Chest with/without Contrast - Sternomanubrial effusion 2.3 cm posteriorly - R 1st rib Osteomyelitis - R supraclavicular clavicle fluid collection 4.6 x 1.5 x 2.6 cm FINAL/WORKING DIAGNOSIS: Septic Arthritis TREATMENT AND OUTCOMES: 1. Source unable to be found: echocardiogram WNL, drug screen negative, HIV/Hepatitis B & C/EBV/Thyroid studies negative, esophagram WNL 2. Blood cultures positive for MSSA. IR aspiration of body fluid performed without speciation. PICC line placed with 8 weeks of IV cefazolin. 3. Hospital course complicated by non-occlusive thrombus in R subclavian/proximal SVC - started on apixiban for 6 months. 4. Serial CT with resolution of infection. One month inpatient, discharged to outpatient rehabilitation. 5. Pending outpatient ID and CT surgery, serial vascular imaging.

NUTS IN THE LUNGS: AN UNFORTUNATE RIME

TYPE: Abstract Publication TOPIC: Lung Cancer PURPOSE: Nuclear Protein in Testis (NUT) Carcinoma is an extremely rare and undifferentiated malignancy characterized by the rearrangement of NUT gene. Typically affects midline structures in younger individuals. We report a case of a NUT Carcinoma of the Lung. METHODS: A 51-year-old female non-smoker with no significant past medical history was presented to a hospital with fatigue and left anterior pleuritic chest pain for 2-weeks. She was performed a chest radiography which showed a homogeneous opacification with concave upper margin in left lower hemithorax, suggestive of pleural effusion. Computed Tomography (CT) scan confirmed a massive pleural effusion associated with pleural thickening. Diagnostic thoracentesis was performed and was suggestive of exudative effusion with no detection of malignant cells. Blind pleural biopsy showed tumoral cells with high proliferation rate (Ki67 50%). Following surgical pleural biopsy and immunohistochemical analysis identified a NUT Carcinoma. 18F-Fluorodeoxyglucose Positron Emission Tomography scan for staging confirmed a left pleural thickening (SUV: 11.7), revealing also bilateral mediastinal ganglion, left adrenal and multiple lithic bone metastasis. RESULTS: The patient was proposed to clinical trial but died 1 month after the diagnostic, due to rapid progression of the disease, invading left main bronchus, vascular structures and pericardium with large pericardial effusion. CONCLUSIONS: NUT carcinoma is a highly aggressive disease that can also affect non-middle structures. CLINICAL IMPLICATIONS: Due to its rarity and lack of experience it can be un/misdiagnosed. NUT Carcinoma should be included in differential diagnosis of rapid progressive malignancy in children and young adults. DISCLOSURE: No significant relationships. KEYWORD: NUT Carcinoma

Anterior chest pain as an unusual initial presentation in pediatric spinal arteriovenous malformations

Anterior chest pain as an unusual initial presentation in pediatric spinal arteriovenous malformations

Instant orthopnea and pseudo-cardiac dilatation due to anterior mediastinal tumor.

A 45-year-old woman presented with instant orthopnea and enlarged cardiomediastinal silhouette in her chest radiograph. Although anterior mediastinal tumor can be misdiagnosed as heart failure due to orthopnea with enlarged cardiomediastinal silhouette, "instant orthopnea" may be a useful sign to distinguish these conditions.

P186 In search of lost time

Abstract Arrhythmogenic right ventricular dysplasia (ARVD) is one of the most difficult to diagnose and manage of the cardiomyopathies. Physical exercise can be a contributing factor and may accelerate the progression of the disease. We present the case of a 49-year-old, a former professional football player, with a history of cardiac arrest in 2011 by ventricular tachycardia (VT) (normal coronary arteries). Between 2011 and 2019 the patient didn"t present for reevaluation and resumed endurance sports activity in spite of doctor recommendation. In 2019 he was directed to our clinic for a syncope followed by constrictive anterior chest pain and palpitations, the clinical expression of a VT with LBBB morphology and inferior axis, most likely originated in the RVOT, for which cardioversion was required. Upon admission, the patient was hemodynamically and respiratory stable, at sinus rhythm 60/min with left anterior hemiblock and negative T waves in V1-V2. Biologically, myocardial and hepatic cytolysis enzymes were within normal limits, with mild hypokalemia. Echocardiography showed significant dilatation of RV and RVOT with RV dysfunction (TAPSE 16 mm, FAC 20%, s" 8.6 cm/s). LV was nondilated, with normal systolic function and kinetic, but with trabeculation of the apex. To confirm the diagnosis of ARVD, cardiac MRI was performed and confirmed fat infiltration in the RV free wall with biventricular involvement. Given the high arrhythmic risk (two resuscitated VT episodes, syncope), a two-chamber ICD was implanted, without immediate post-procedural complications. In the second postprocedural day, the patient suddenly installed important epigastric pain with thoracic irradiation. The ECG showed sensing and pacing malfunction and radioscopy showed evidence of ventricular probe displacement. The echocardiography confirmed the myocardial perforation. Emergency surgery by median thoracotomy was performed, with successful extraction of the electrode and myocardial suture. Postoperative progression was favorable under treatment with beta-blocker and amiodarone. A subcutaneous ICD will be implanted as soon as available. In conclusion, this case is a very particular one. First of all, we’ve documented two distinct phases in the evolution of the ARVD (electrical phase – 2011 and structural phase - 2019). Moreover, by resuming endurance sports activity and in concordance with the literature data, we can only assume that the progression of the disease was accelerated and the arrhythmic risk was greater. Complications related to probe stability are common in this population, but myocardial perforation is a very rare and dangerous one. The therapeutic management of patients with ARVD has evolved over the years and continues to be an important challenge. To further improve risk stratification and treatment of patients, more information is needed on the natural history, long-term prognosis, and risk assessment. Abstract P186 Figure. Echocardiografic and MRI aspect

Treatment of Isolated Sternal Fracture with Ultrasound-Guided Paravertebral Nerve Block: a Case Report and Literature Review

In the case of isolated sternal fractures, conservative treatment with analgesics is common, but pain can persist for more than 10 weeks, which can significantly interfere with daily life. Ultrasound-guided paravertebral nerve block is reported to be a successful means of pain control in patients with chest wall injury or rib fracture.A 70-year-old female patient presented with anterior chest pain that had persisted for 2 weeks despite conservative treatment. Sagittal reconstruction chest computed tomography and sternum lateral oblique x-ray revealed an isolated sternal fracture. An ultrasound-guided bilateral paravertebral nerve block was performed for pain control. After performing the procedure twice at a 1-week interval, the patient reported complete pain alleviation, and no other problems were observed over the 3-month follow-up period.Ultrasound-guided bilateral paravertebral nerve block can help patients with isolated sternal fractures to manage pain and return to normal activities sooner than with oral analgesics.

Unusual Presentation of a Rare Chest Wall Tumor: Giant Cell Tumor of Bone

Introduction: Giant cell tumours account 5% of all bone tumours. However, the anterior chest wall is rarely involved . Clinical case: This is a 68-year-old housewife who has been thyroidectomized, for 11 years and is under hormone replacement therapy, and hysterectomized for 6 years after a uterine tumor. She is present for the onset of a 5 month old hard submammary mass on the left associated with left anterior chest pain under mammals. The clinical examination had found an irregular hard mass under left mammary which is fixed to the anterior arch of the 4th left rib. A thoracic x-ray showed a limited left hilo-axillary with an homogenously dense opacity. The thoracic CT scan showed the presence of a thoracic parietal mass of osteolytic tissue density centered on the anterior arch of the 4th left rib; without contrast agent, the surgical exploration through thoracotomy revealed a thoracic parietal tumoral process at the expense of the anterior arch of the 4th limb pushing the corresponding lung inwards. Surgical excision allowed ablation of the whole tumor in monobloc towards a healthy zone. The anatomopathological study of the operative specimen showed a morphological and histopathological aspect compatible with a costal tumor with giant cells. The postoperative recovery was marked by a good clinical and radiological improvement. The last check up after the surgery revealed that the patient was still asymptomatic. Good clinical, biological and radiological improvement was noted with a decline of 8 months. Conclusion: Giant cell tumors are aggressive bone tumors, yet histologically benign. The chosen examination is a thoracic CT scan with surgical treatment. A clinical and radiological monitoring is necessary. The recurrence is rare, but it usually necessitates a second surgery. The objective of this clinical observation is to highlight the possibility, although rare, of a giant cell tumor in case of the swelling of the soft parts, and a lytic lesion of the anterior part of a rib. Therefore, this tumor must be added to the list of diagnoses to be mentioned in this situation.

An Unexpected Etiology of Myocardial Ischemia in Young

Introduction The cardiac localization of hydatid cyst (HC) is rare and little known. It is exceptionally primary and isolated. Myocardial ischemia remains an exceptional and unusual manifestation of this localization. We report the original observation of cardiac HC revealed by acute myocardial ischemia in a young subject. Observation A 35-year-old patient with no notable pathological history was admitted to our department via the emergency room for acute anterior chest pain. The somatic examination was without abnormalities as well as the baseline biological tests. The electrocardiogram demonstrated epicardial ischemia in the infero-lateral territory without other abnormalities. The cardiac troponin I was slightly elevated (32ng/l, N<19ng/l). Subsequent controls after 30min, 60min and 180min did not show significant variations. Subsequent investigations (CT, coro-CT, coronary angiography) led to the diagnosis of intramyocardial HC of the left ventricle, with no abnormalities of the coronary arteries. After surgical excision, the evolution was favorable with normalization of the electrocardiogram and the troponin Ic. Conclusion Cardiac localization of this parasitosis is exceptional and characterized by an important clinical polymorphism making its diagnosis a real challenge. It seems useful to discuss the diagnosis of cardiac HC in front of any unexplained electrocardiogram abnormality occurring in endemic zone.