Intermittent Chest Pain Research Articles

A case of pulmonary aspergilloma and actinomycosis

Pulmonary aspergilloma and pulmonary actinomycosis are rare pulmonary infectious diseases. Clinical manifestations of pulmonary aspergilloma and pulmonary actinomycosis include chronic cough, fever, chest pain, haemoptysis and other pathologies, but some patients may be asymptomatic. We report a case of a healthy 33-year-old woman without any underlying diseases, who was admitted to Zhongxing Branch of Taipei City Hospital, Taiwan, for intermittent haemoptysis and right upper chest pain, which had persisted for several months. A chest radiograph revealed a focal consolidation in the right upper lobe (RUL) of the lung, which grew in size over time. A sputum study and bronchoscopy revealed no positive findings, although malignancy could not be ruled out. Thus, the patient received a wedge resection of the RUL lesion. Subsequent, pathological examination demonstrated the presence of pulmonary aspergilloma and pulmonary actinomycosis. The patient's symptoms resolved after resection of the RUL lesion.

Asymmetric septal hypertrophic cardiomyopathy: a case report

We report the case of a 30-year-old female who presented to the emergency department with the chief complaint of syncope. She also described intermittent chest pain and exertional dyspnea over the past several weeks. Review of systems and laboratory findings including D: -dimer levels were noncontributory. EKG demonstrated right bundle branch block. Nongated chest CT with contrast was ordered to exclude the possibility of pulmonary embolism demonstrating markedly asymmetric septal thickening. Suspicion for hypertrophic cardiomyopathy was raised, which was subsequently confirmed on gated cardiac MRI.

A 53-Year-Old Man With Dysphagia, Anorexia, and Night Sweats

A 53-year-old man complaining of cough was admitted to the hospital. Four months previous, he developed subjective fevers and night sweats, requiring him to change his sheets nightly. He also complained of intermittent chest pain that worsened with deep inspiration.

A Case of Symptomatic Diffuse Esophageal Spasm During Multiple Rapid Swallowing Test on High-Resolution Manometry

Diffuse esophageal spasm (DES) is an uncommon motility disorder of unknown etiology in which the abnormal motility has been offered as a possible cause for the patient's dysphagia or chest pain. Esophageal manometry is the gold standard for the diagnosis of DES and the diagnostic hallmark is identification of simultaneous contractions in at least 20% of wet swallows, alternating with normal peristalsis. Recently, a new diagnostic technique, high-resolution manometry has been reported to improve the accuracy and detail in describing esophageal function. We report a female patient with intermittent dysphagia and chest pain occurring only when swallowing a large amount of water. On HRM, this patient had esophageal spasms, increased pressurization front velocity attributable to rapid contractile wave front, associated with symptoms, which were provoked by a multiple rapid swallowing test, and thereby was diagnosed with DES.

E0387 Percutaneously intervention was successfully performed in right coronary artery combined with right sinus of valsalva aneurysm

IntroductionSinus of Valsalva aneurysms (SVA) are rare cardiac anomalies. They may be congenital or acquired and are usually asymptomatic unless complicated by such developments as intracardiac rupture with formation of...

Intermittent chest pain with marked ST depression after 13years of aortic valve replacement.

An 80-year-old woman who underwent aortic valve replacement with a 19-mm Medtronic Hall prosthetic valve in 1993 was admitted because of intermittent chest pain. Electrocardiography on admission revealed non-specific changes, but electrocardiography during chest pain revealed significant ST depression. Coronary angiography revealed no significant stenosis. Echocardiography revealed intermittent severe aortic regurgitation and incomplete closure of the prosthetic valve in diastole. An urgent operation was performed, and abnormal pannus formation was observed at the left ventricular side of the prosthetic valve. In this case, intermittent diastolic valvular sticking caused severe aortic regurgitation and induced serious myocardial ischemia.

Case 28-2010

A 32-year-old woman, 3 weeks post partum, was seen in the emergency department because of intermittent substernal chest pain. The pain had developed suddenly during normal activity, resolved after 20 minutes, and then recurred. Diagnostic procedures were performed.

NICE clinical guideline: chest pain of recent onset

Chest pain is a common presentation in general practice: in the UK, up to 1% of visits to a GP are due to chest pain.1 Chest pain matters: the risk of death is doubled in the year following a new presentation with chest pain in general practice.1 The recently published guideline from the National Institute for Health and Clinical Excellence (NICE), Chest Pain of Recent Onset: Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin ,2 addresses the assessment and diagnosis of patients with recent-onset chest pain (or discomfort) that may be of cardiac origin. It does not make recommendations for the management of the condition once the diagnosis is made. The NICE unstable angina and non-ST elevation myocardial infarction (NSTEMI) clinical guideline3 was published at the same time as the chest pain guideline; local protocols are recommended for management of STEMI, and a NICE clinical guideline for the management of stable angina is currently being prepared.4 The chest pain guideline has two separate diagnostic pathways. The first is for patients with acute chest pain who may have an acute coronary syndrome (ACS), and the second for those with intermittent stable chest pain who may have stable angina. The need to provide information to patients (and, where appropriate, their family or carer/advocate) and to involve them in decisions is emphasised throughout. The recommendations around acute and ‘acute but not current’ (that is, recent pain but currently pain free) chest pain are summarised in Boxes 1 and 2. For chronic stable chest pain, a key aspect of the guideline of particular relevance to primary care is the recommendation that formal risk stratification of the likelihood of coronary artery disease (CAD) be undertaken, based on aspects of the history (Box 3 …

Congenital Left Ventricular Diverticulum in a Patient With Coronary Artery Disease

Congenital ventricular diverticulum is rare. We present the case of a 76-year-old man who underwent cardiac multidetector computed tomography (MDCT) for recent intermittent chest pain. Obstructive single-vessel coronary artery disease was diagnosed. A left ventricular diverticulum of about 10 x 9 mm was found incidentally. Conventional angiography confirmed both diagnoses. Ventricular diverticulum may be more frequently found in the era of cardiac MDCT and should be differentiated from postinfarct (pseudo)-aneurysm.

Congenital cystic adenomatoid malformation of the lung associated with bronchial atresia involving a different lobe in an adult patient: a case report

IntroductionCongenital cystic adenomatoid malformation of the lung is an uncommon cause of respiratory distress in neonates and babies. The disorder is usually diagnosed in the neonatal period and the first two years of life. This anomaly has been described in association with bronchopulmonary sequestration, extralobar intra-abdominal sequestration or bronchial atresia in live and stillborn babies. It is rarely encountered in adults, in whom the diagnosis is made incidentally from mass lesion features seen on chest radiographs. The oldest patients recorded with this malformation have been about 35 years old, and only 10% of primary diagnoses are made after the first year of life. Delayed diagnosis can be related to infection or serendipitous discovery.Case presentationWe describe the radiological findings of a 34-year-old Caucasian woman with a clinical history of recurrent pneumonia, intermittent anterior pleuritic chest pain and haemoptysis. Congenital cystic adenomatoid malformation of the lung associated with bronchial atresia involving a different lobe was discovered.ConclusionAlthough rare in adults, congenital cystic adenomatoid malformation should be suspected in adult patients who suffer from recurrent or persistent non-productive coughs. The discovery of an association of congenital cystic adenomatoid malformation with bronchial atresia in adulthood is rare but possible, even in different lobes.

Hemoptysis caused by erosion of thoracic aortic aneurysm

A 68-year-old woman presented with a five-month history of dry cough and intermittent fever. During the previous month, she had intermittent retrosternal chest pain radiating to her back. Two days before presentation, she had coughed up about 5 mL of blood on two occasions. She had type 2 diabetes

Painful Purple Toes

A 57-year-old man presented to the emergency department with painful purple discoloration of three toes on his left foot. He had also had intermittent blurry vision, intermittent chest pain, fatigue, anorexia, drenching night sweats, and a weight loss of 7 kg (15 lb) over the previous 3 weeks. His roommate commented that the patient had been slightly confused.

Piperacillin-Associated Pulmonary Infiltrates with Eosinophilia: A Case Report

A case of pulmonary infiltrates with eosinophilia attributed to piperacillin tazobactam therapy is described. A 54-year-old woman was treated for a suspected severe urinary tract infection with piperacillin tazobactam. Four days later, she developed fever, chills, shortness of breath and intermittent chest pains. Eosinophilia was noted in peripheral blood and, subsequently, on bronchoalveolar lavage. Transbronchial biopsy showed tissue infiltrates with eosinophilia. No evidence of bacterial, fungal and parasitic infection, or vasculitis was observed. Her symptoms and peripheral eosinophilia subsided after drug discontinuation and oral prednisone treatment. Piperacillin is an extended-spectrum penicillin antibiotic prescribed for moderate to severe infections. The common adverse reactions to piperacillin include nausea, vomiting, diarrhea and rash. Pulmonary infiltrates with eosinophilia is a rare adverse reaction, but one that may result in significant morbidity. Physicians should be aware of this rare but important adverse reaction to piperacillin.

Chest Pain in Children and Adolescents

1. Surendranath R. Veeram Reddy, MD* 2. Harinder R. Singh, MD* 1. *Division of Cardiology, The Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Mich After completing this article, readers should be able to: 1. Enumerate the most common causes of chest pain in pediatric patients. 2. Differentiate cardiac chest pain from that of noncardiac cause. 3. Describe the detailed evaluation of a pediatric patient who has chest pain. 4. Screen and identify patients who require a referral to a pediatric cardiologist or other specialist. 5. Explain the management of the common causes of pediatric chest pain. ### Case 1 During an annual physical examination, a 12-year-old girl complains of intermittent chest pain for the past 5 days that localizes to the left upper sternal border. The pain is sharp and stabbing, is 5/10 in intensity, increases with deep breathing, and lasts for less than 1 minute. The patient has no history of fever, cough, exercise intolerance, palpitations, dizziness, or syncope. On physical examination, the young girl is in no pain or distress and has normal vital signs for her age. Examination of her chest reveals no signs of inflammation over the sternum or rib cage. Palpation elicits mild-to-moderate tenderness over the left second and third costochondral junctions. The patient reports that the pain during the physical examination is similar to the chest pain she has experienced for the past 5 days. A detailed cardiovascular and other organ system examination yields normal results. What is the most likely cause of this patient's chest pain? What will you recommend for this patient? Does she need to see a pediatric cardiologist? ### Case 2 A 17-year-old boy is playing soccer on a Saturday afternoon and has a syncopal event on the field. He regains consciousness within a few seconds, does not require resuscitation, and is taken to the emergency department. The patient informs the physician that he developed sudden midsternal chest pain and lightheadedness prior to passing out. His vital signs are normal for age, and he is …

Pulmonary epithelioid hemangioendothelioma: A rare pulmonary tumor in differential diagnosis of bronchogenic carcinoma

Sir, A 33-year-old female was admitted to our institute with complaints of dry cough with minimal expectoration and two episodes of hemoptysis in the last four years. She was also complaining of intermittent chest pain and loss of appetite but without any weight loss for last four months. She had no prior medical history, was a non-smoker, and denied any history of exposure to pets or birds. There was no other family history of cancer. She was average built and, on physical examination, showed no clubbing of fingers and toes, no enlarged lymph nodes. Lung examination revealed minimal inspiratory crackles at the left base without any added sounds or evidence of consolidation. Routine blood investigations were in normal limits. Sputum smears were negative for acid fast bacilli, fungal elements and malignant cells. Chest radiograph showed about 6 × 6 cms round opacity in mid zone of left lung [Figure 1]. Contrast enhanced computerized tomographic (CT) scan of thorax showed heterogeneously enhancing soft tissue density mass lesion in apical segment of left lower lobe [Figure 2]. CT guided needle aspiration cytology of mass showed atypical epithelial cells along with keratinous material and was suspicious of squamous cell carcinoma. Ultrasound abdomen was normal. No endobronchial lesions were found at fiber optic bronchoscopy. Pulmonary function tests were within normal range. Under general anesthesia, we found a 7 × 7 cms firm vascular mass, of heterogeneous consistency, cystic in between and involving major fissure with both lobes of left lung without any pleural and vascular invasion. Left sided extra pericardial pneumonectomy was done. Postoperative course was uneventful and she was discharged after a week in satisfactory condition. Biopsy of specimen diagnosed it as epithelioid hemangioendothelioma of lung. Later, immuno-histochemistry was done for confirmation of the diagnosis, vascular tumor markers CD31 (CD = cluster of differentiation- antigen class) and CD34 (CD = cluster of differentiation- antigen class) were positive. Patient survived without any morbidity and is doing well so far (postoperative three years). Due to asymptomatic nature, no additional imaging modalities were done.Figure 1: Chest radiograph shows a rounded mass lesion in the left hemithorax without any associated bony abnormalityFigure 2: Computed tomography (CT) scan shows a well defined mass in the left lung; there was no hilar or mediastinal lymphadenopathy in the mediastinal windowsThe tumor was initially described in 1975 by Dail and Liebow and named “intravascular sclerosing bronchioalveolar tumor” (IVBAT) because of the proposed bronchioalveolar origin of the neoplasm. Enzinger and Weiss (1988) first used the term hemangioendothelioma. Now it is recognized that this is the pulmonary counterpart of epithelioid hemangioendothelioma, which is sclerosing true neoplasm of vascular endothelium of low grade to borderline malignancy potential and occurring around medium to large size veins in soft tissue, occurring also in other anatomical sites.[1–3] Three quarters of patients with epithelioid hemangioendothelioma of the lung are women. The age range at presentation is wide (12 - 60 years). Half the patients are asymptomatic and are discovered on incidental chest radiography. Symptoms are uncommon and are usually include dyspnea, mild pleuritic pain, non-productive cough and rarely hemoptysis. The chest radiograph usually reveals multiple or bilateral pulmonary nodules. Pleural effusions and distant metastases are rarely seen.[1–3] Histology is diagnostic for these tumors.[13] The characteristic immunophenotype is negative for epithelial, muscular, and neural markers, and positive for vascular markers such as factor VIII, CD31 (Most specific and sensitive endothelial marker), CD34, von Willebrand's factor, and Ulex europaeus antigen (UEA-1). Ultra-structural endothelial characteristics can be confirmed by electron microscopy, which shows the presence of prominent basal lamina, pinocytotic vesicles, and Weibel-Palade bodies.[134] Because of the rarity of this condition, there is no clear standard for treatment. In most cases, the disease has a slowly progressive course. Apparently, benign lesions of hemangioendothelioma are best treated by wide local excision and apparently malignant ones by radical excision.[134] Epithelioid hemangioendothelioma is a rare pulmonary neoplasm of vascular origin with fewer than 50 cases reported in the literature.[35] We report one such case with an initial presentation mimicking bronchogenic carcinoma but proven to be pulmonary epithelioid hemangioendothelioma on histopathological and immunohistochemical examination of the surgically resected tumor. It is also unusual because of the solitary nature.

Multiple Coronary Arteriovenous Fistulas to the Coronary Sinus With an Unruptured Coronary Sinus Aneurysm and Restrictive Coronary Sinus Opening to the Right Atrium

A 37-year-old woman was transferred to our department for surgery. She had experienced intermittent chest discomfort or pain and palpitation during the last 4 years. Chest radiographs showed cardiomegaly (cardiothoracic ratio 0.63). A preoperative ECG showed normal sinus rhythm (Figure 1). Echocardiography showed marked dilatation of the coronary sinus with an intramural thrombus and flow acceleration at its opening (Figure 2). Cardiac catheterization showed no significant coronary artery stenosis but revealed coronary arteriovenous fistulas (CAVFs) from the distal right coronary artery, distal left anterior descending artery, and proximal left circumflex artery draining directly into the coronary sinus (Figure 3). A preoperative computed tomography scan showed a large aneurysm that contained thrombi with a maximal diameter of 73 mm at the outer side of the left ventricular inferior wall (Figure 4). The site of the aneurysm coincided with the coronary sinus and greater cardiac vein. The computed tomography scan was unable to reveal drainage of the thrombosed aneurysm into the right atrium (RA). Magnetic resonance imaging, however, showed a pinpoint opening from the coronary sinus aneurysm to the RA (Figure 5). The right coronary artery was diffusely dilated and was connected to the coronary sinus after forming a small coronary artery aneurysm. Distal collateral vessels from the left anterior descending artery and left circumflex artery were connected directly to the coronary sinus (Figure 6). On …

Successful Retrial of ECT Two Months After ECT-Induced Takotsubo Cardiomyopathy

heart failure; however, recovery of cardiac function is often complete within the first week following the insult. Cardiac enzymes may be mildly elevated, but on cardiac catheterization there is usually no evidence of coronary artery disease, or only "mild luminal irregularities" may be noted (7). Contraction band necrosis may be seen on biopsy in the more serious cases. The cause of takotsubo cardiomyopathy is unknown, but several mechanisms have been suggested, including ischemia from coronary artery spasm, microvascular spasm, and direct myocyte injury (5).

Case 14-2009

A 36-year-old man was admitted to the hospital because of chest pain, dysphagia, and pleural and mediastinal calcifications. He had had intermittent chest pain for 6 years after an athletic injury; dysphagia, dyspnea, and weight loss had developed over the past 2 years. Imaging studies showed pleural and mediastinal calcifications, with an esophageal stricture. Surgical procedures were performed to relieve esophageal stricture and obtain tissue for diagnosis, but symptoms recurred and biopsy specimens disclosed bony tissue with no malignant cells.

No Symptoms, No Stress

In evaluating a patient presenting with intermittent chest pain, the emergency room physician must be alert to subtle electrocardiogram (ECG) abnormalities. Even in a patient with no known risk factors for cardiovascular disease, no current symptoms, and normal cardiac enzyme levels, some very minor ECG abnormalities can have prognostic value when considered in light of the clinical history.

Delayed fistulisation from esophageal replacement surgery

We present two patients who developed delayed fistulization following esophageal replacement surgery. The first is a 13-year-old child who, at the age of 3 years, underwent a trans-mediastinal colonic esophageal replacement for a refractory corrosive injury followed by a retrosternal reverse gastric tube after an early catastrophic leak. Ten years later, he presented with a history of intermittent chest pain for 6 months. He developed a tension pneumo-pericardial tamponade caused by a fistula between gastric tube and pericardium. He recovered after sternotomy. The second was born prematurely with type C esophageal atresia and other malformations. After esophageal anastomosis, he developed a refractory stricture that was resected at 10 months. Despite a fundoplication at 4 years, the recurrent esophageal stricture required resection at 14 years, accomplished by mobilizing the stomach into the chest through a left thoracoabdominal incision. The postoperative course was complicated by a gastric leak in the chest with empyema, but the patient recovered and was able to eat. Five years later, he underwent an anterior spinal fusion to correct a worsening kyphoscoliosis. Postoperatively, he developed an ARDS picture, leakage of air through the gastrostomy, and a fatal pulmonary hemorrhage secondary to a gastro-bronchial fistula. Fistulization from esophageal replacement surgery represents a rare long-term complication that pediatric surgeons need to be aware of.