Sudden Chest Pain Research Articles

ATYPICAL PRESENTATION OF AORTIC DISSECTION DURING COVID-19 PANDEMIC

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Aortic dissection (AoD) is extremely rare, with an annual incidence of 2.5-3.5 per 100,000 persons and a mortality rate between 13% - 50%. AoD commonly presents with either sudden onset chest pain or back pain, with systemic hypertension being the most significant predisposing risk factor. We report an atypical presentation and unfortunate misdiagnosis of aortic dissection during the COVID-19 pandemic that could further improve this patient population's screening and outcomes. CASE PRESENTATION: A 59 year old male with a history of hypertension was transferred to our institution for Neurosurgery evaluation due to head CT results consistent with subarachnoid hemorrhage. Repeated images revealed normal findings. Upon arrival, he presented with blood pressure readings of 252/110 mmHg accompanied by altered mental status. Further questioning of the patient's spouse revealed the patient's non-compliance with his antihypertensives, and abuse of energy drinks (> 4 drinks/day). In addition she revealed that symptoms began one day prior to admission, as the patient stood in the living room and reported an intense, non-localized headache accompanied by loss of sensation in lower extremities and loss of consciousness. Physical examination was remarkable for obesity, drowsiness, epigastric tenderness, and no focal neurologic deficits. The patient was admitted with an initial diagnostic impression of hypertensive emergency with the CNS as target for which Clevidipine drip was started. Given the marked clinical deterioration 48 hours after admission consisting of an elevated temperature, tachycardia, and leukocytosis during the COVID-19 pandemic led to suspicion, PCR testing and isolation. The PCR was non-reactive. Portable Chest X-Ray report yielded a magnification of cardiomediastinal silhouette with mediastinal widening. Subsequent chest and abdominal/pelvic CT confirmed the suspected diagnosis of AoD. Cardiology and Endovascular Surgery were consulted for further management. Recommendations were given against surgical management. After 35 days of hospitalization, the patient was discharged in a stable condition. DISCUSSION: AoD are caused by a tear in the aortic intima creating a false lumen. Despite the rarity of AoD, it has typical findings. Pain, most commonly in the chest and back, is present in over 90% of AoD patients, all of which were absent in our patient. Transient neurological symptoms including altered mentation;and elevated blood pressure readings, must be evaluated for aortic dissection when risk factors are present despite concurrent inflammatory responses amid a pandemic. CONCLUSIONS: A new pandemic and the surrounding uncertainty can influence but most not be allowed to sway other differential diagnoses. It is of utmost importance to recognize atypical presentations in high risk populations in order to obtain better outcomes. REFERENCE #1: Astarita A, Covella M, Vallelonga F, et al. Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis. J Hypertens 2020;38:1203. REFERENCE #2: Martin JF, Higashiama E, Garcia E, et al. Hypertensive crisis profile. Prevalence and clinical presentation. Arq Bras Cardiol 2004;83:131. REFERENCE #3: Clouse WD, Hallett JW Jr, Schaff HV, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc 2004;79:176 DISCLOSURES: No relevant relationships by Felix Aponte Santos, source=Web Response no disclosure on file for Andres Cordova Toro;No relevant relationships by Adriana Suarez Cruz, source=Web Response

Tako-Tsubo Syndrome Induced by Emotional Stress Leading to Cardiogenic Shock and Cardiocirculatory Arrest in a 56 Old-Year-Old Patient with Deficit of Protein C

Transient left ventricular (LV) dysfunction syndrome, or Tako-tsubo syndrome, occurs following intense emotional or physical stress and simulates the clinical presentation of an acute myocardial infarction. The prognosis is favorable with normalization of wall motion abnormalities within weeks. In this case we report a young female patient who developed sudden chest pain and consciousness disorder after a profound stress (mother’s death).The patient had characteristic feature of progressive pulmonary edema. Her symptom worsened gradually leading to herintubation. An immediately performed echocardiography showed akinetic mid-to-distal portion of the left ventricular chamber and hyperkinetic activity in basal segment with an ejection fraction (EF) of 25%. Coronary angiography showed normal coronary arteries. After 6 days of monitoring she was extubated and had a cardiac MRI that confirmed the diagnosis of tako-tsubo.

Spontaneous Coronary Artery Dissection in Multiple Gestation Peripartum Period

Background: Non-atherosclerotic spontaneous coronary artery dissection (SCAD) is defined as a non-traumatic and non-iatrogenic separation of the coronary arterial wall. SCAD is a highly uncommon cause of myocardial infarction (0.1 to 0.4 %).
 Case presentation: 40-year-old African American woman, G1T1P0A0L2, with a past medical history of tobacco abuse and obesity who had uncomplicated cesarean section delivery for healthy twins two weeks prior presented with substernal, sudden onset chest pain. The pain radiated to left arm and back, pressure-like, and is associated with nausea, vomiting, and dyspnea.
 On examination she was within normal limits except for a well-healed C-section wound. An electrocardiogram showed normal sinus rhythm with Nonspecific ST Abnormality. The first set of troponins less than 0.03, the second set shows troponins 0.18 and D-dimer 2340. The chest x-ray was unremarkable. An echocardiogram showed only mild to moderate mitral valve regurgitation. CT angiography of the chest showed no evidence of pulmonary embolism. She was started on a heparin drip and catheterization the next day showed no atherosclerotic coronary artery disease, but SCAD of inferior diagonal first branch noted. No intervention was done, heparin was stopped. The patient was started on aspirin, statin, Clopidogrel, Metoprolol, and Lisinopril per cardiology recommendation.
 Conclusions: As an internist and primary care provider, we should keep Non-atherosclerotic SCAD in mind when a young female patient presents with acute chest pain. More studies are needed to find out the optimal management.
 Current recommended conservative medical management includes long-term aspirin, beta blocker, and one year of clopidogrel, with the addition of a statin in patients with dyslipidemia.

Spontaneous Coronary Artery Dissection as Presenting Feature of Vascular Ehlers-Danlos Syndrome

A spontaneous coronary artery dissection as the sole presenting feature of vascular Ehlers-Danlos syndrome is an uncommon finding. We present a 33-year-old woman with sudden onset chest pain caused by a spontaneous coronary artery dissection. Genetic testing revealed vascular Ehlers-Danlos syndrome as the underlying cause. Specifically, we show the value of genetic testing, which in some patients may be the only way of establishing a diagnosis.

Sudden Chest Pain During Vomiting After Drinking

Question: A man in his 40s visited a nearby hospital for a consistent chest pain, which suddenly occurred a few days before while vomiting after drinking. He was a heavy drinker. Body temperature was 37.2°C, and blood tests showed elevated white blood cells and C-reactive protein. Computed tomography (CT) showed intramural emphysema in the esophagus from the neck to the lower chest, but no mediastinal emphysema (Figure A and B). Esophagogastroduodenoscopy (EGD) showed a 2-cm-long mucosal laceration in the upper esophagus (Figure C).

Stanford type A acute aortic dissection with proximal intimo-intimal intussusception: a case report and literature review

BackgroundAcute aortic circumferential dissection with proximal intimo-intimal intussusception is a rare and potentially lethal occurrence. We here report a case and review previous works to better understand this particular condition and help surgeons to determine accurate diagnosis and optimal intervention strategies by intraoperative transesophageal echocardiography (TEE).Case presentationWe report a case of a 46-year-old male who complained of sudden substernal chest pain. Stanford type A acute aortic dissection with proximal intimo-intimal intussusception was confirmed by contrast-enhanced computed tomography (CECT), transthoracic echocardiography (TTE), and TEE. We found the intimal flap prolapsed into the left ventricle outflow tract (LVOT), which caused severe aortic regurgitation (AR) and obstructed the ostia of the coronary arteries. Given the preexisting aneurysmal dilatation of aortic sinus and severity of aortic root and arch dissection, Bentall procedure and Sun’s procedure were performed for our patient.ConclusionsIntraoperative TEE used by anesthesiologists here played an increasingly valuable role in the determination of acute aortic dissection. Hence, it is necessary that TEE screening is routinely performed in patients with acute aortic dissection to provide valuable information for facilitating surgical strategies.

A Case of Idiopathic Thoracic Spinal Subdural Hematoma With Bilateral Lower Limb Paralysis

Subdural hemorrhage is rare and is mostly triggered non-traumatically due to intracranial surgery, lumbar puncture, anticoagulant therapy, blood diseases, vascular malformations, and tumors. We experienced a case of idiopathic subdural hematoma with acute bilateral lower limb paralysis on postoperative day 4 after laparoscopic hysteromyomectomy.The patient was a 40-year-old woman with uterine myoma who took no medication nor had history of trauma or abnormalities such as vascular malformations. Four days after laparoscopic surgery, sudden chest and back pain and bilateral lower limb paralysis appeared. Muscle weakness was found predominantly on the left side. In manual muscle test (MMT), the quadriceps femoris was 5/5 on both sides, but the tibialis anterior, extensor pollicis longus and flexor pollicis longus were 5/5 only on the right, and 2/5 on the left side. Warm pain sensation was decreased below Th4 (Fourth thoracic vertebra), and the right side showed a greater decrease of deep sensation than the left. Excretion was difficult and dysuria was also apparent. There were no abnormalities in blood biochemical tests or in the blood coagulation system. Using the results of diagnostic imaging, as preoperative diagnosis of the patient, spinal subdural hematoma was suspected. Conservative treatment was initially conducted but the emergency surgery for hematoma removal was performed at 14 hours after the onset because of progression of paralysis. This resulted in improvement of neurological symptoms including lower limb paralysis, bladder-rectal disorder and hypoesthesia.If subdural hematoma is suspected regardless of the cause, it is important to observe neurological findings over time and make a quick decision to treat with surgery.

Impact of the COVID-19 pandemic on patients with rupture of intracranial aneurysm at the Dos de Mayo National Hospital in Lima Peru

Objective: To evaluate the impact on the outcome of patients with a ruptured aneurysm, who are admitted to the Dos de Mayo National Hospital in the context of the COVID-19 pandemic. Methods: 42 operated for ruptured aneurysms were included in the context of the COVID-19 pandemic between March 1 and December 31, 2020 (group A), and a control group of 44 patients operated on between March 1 and December 31, 2019 (group B). Upon admission, the poor neurological status defined by the WFNS> 3, the Fisher IV high-grade tomographic status with intracerebral hematoma or acute hydrocephalus, which required external ventricular drainage (EVD), and the presence of vasospasm were evaluated. The Modified Rankin Scale was evaluated at discharge. Statistical analysis was performed to compare both groups. Results: The rates of poor neurological presentation and complications during the presurgical evolution (intracerebral hemorrhage and acute hydrocephalus that required EVD) were higher in group A (p = 0.002 and p <0.05, respectively). The delay in the admission of the patient to the emergency room to receive treatment was 7.5 days in group A and 4.95 days for group B. All these factors contributed to a lower possibility of recovery in group A, which was correlated with higher Values on the Modified Rankin Scale at discharge for this group (p = 0.04). Conclusion: We did not find national reports on ruptured aneurysms treated in the context of the pandemic, this being one of the first studies that demonstrate the impact of the COVID-19 pandemic in patients with ruptured intracranial aneurysm. The population should be educated on how to act in case of specific symptoms such as sudden intense headache, neurological deficit, or acute chest pain, which should receive timely care, immediate referral, and priority of treatment in referral hospitals in order to reduce morbidity and mortality of complex neurological pathologies. Keywords: Intracranial Aneurysm, Aneurysm, Ruptured, Cerebral Hemorrhage, Pandemics, COVID-19. (Source: MeSH NLM)

Development of a Large Pneumatocele in a Patient Recovering from COVID-19 Pneumonitis.

A 39-year-old man presented with severe COVID-19 pneumonitis requiring hospital admission. He represented three days following discharge with sudden onset breathlessness and chest pain. Initial imaging suggested the presence of a left pneumothorax. Following further clinical decline a plan was made to insert a CT guided chest drain. However, imaging in the prone position for the procedure unexpectedly revealed a large left lower lobe pneumatocele with only a very small pneumothorax. Events and appearances suggest that this is a rare case of delayed COVID-19 pneumonitis-related pneumatocele formation. We will discuss the clinical significance of this entity.LEARNING POINTSPneumatocele formation should be considered in patients presenting with new respiratory symptoms after completing therapy for COVID-19 pneumonitis.Performing CT examinations with patients in different positions may be required to help exclude the possibility of pneumatocele formation when a loculated pneumothorax is suspected on the supine CT images.

Iatrogenic Insertion of Chest Tube inside the Right Pulmonary Artery: Unique, Unheard Complication, and Management

A 75-year-old male patient referred from a medical college for emergency surgical removal of chest tube from the right pulmonary artery, inserted while treating a right-sided pneumothorax. The patient was a known case of COVID pneumonia treated successfully, 2 months back. The patient developed sudden breathlessness and chest pain with saturation of 70%. The patient had gone to nearest medical college for evaluation. Chest X-ray showed right-sided pneumothorax. Chest physician inserted intercostal chest tube. After insertion of chest tube, the patient drained 1500 ml of frank blood. Chest tube clamped and referred to a tertiary care center. Emergency computed tomography (CT) pulmonary angiogram is done. It showed chest tube tip in the right pulmonary artery. In view of post-COVID, severe interstitial lung disease, patient was not suitable for open heart surgery with the support of heart-lung machine. The patient was stable when we were received; saturation was 90% with 5 L oxygen. CT chest showed diffuse fibrosis and resolving pneumonia. Echo showed severe pulmonary arterial hypertension. We did high-risk off- pump right thoracotomy and removed chest tube without much loss of blood. The injured right pulmonary artery repaired. Post-operative period was free of events and discharged successfully. In complicated cases, preferably thoracic surgeon and a well-trained, experienced chest physician should insert chest tube to avoid life-threatening complications.

The blues, and an almost shocking surprise – Unexpected PE in a catatonic patient, that almost had ECT

AimsTo present a case of a near-miss, where an unexpected Pulmonary Embolism (PE) was identified in a patient with psychotic depression and catatonia, who almost had Electroconvulsive Therapy (ECT). Our aim is to highlight the importance of Venous-Thrombo Embolism (VTE) risk assessment in all psychiatric inpatients, particularly those with catatonia, and those about to undergo ECT.MethodA 53-year-old female admitted with her first presentation of psychotic depression, catatonia, poor oral intake, and significant weight loss in the community for months prior to admission. She was recommended for emergency ECT as the severity of her self-neglect was becoming life threatening. Her first ECT session was cancelled due to low potassium levels prior to ECT, which proved to be a fortunate event. She developed sudden onset chest pain the next day, and following further medical investigations; was diagnosed to have a bilateral PE, and subsequently treated with Apixaban. Due to the potential risk of ECT dislodging the clots, treatment was done by optimising medication alone; Venlafaxine 300 mg, Mirtazapine 45 mg, Haloperidol 6 mg. She made a slow but successful recovery, and was discharged home, with ongoing support from Early Intervention in Psychosis services.ResultWe conducted a literature search, and it is well known that there is an increased risk of VTE in catatonic patients, as well as other psychiatric inpatients; due to anti-psychotic medication. Furthermore, cases have been reported where ECT was associated with increased risk of death in patients with known VTE/PE.On retrospective review of the patient's risks of developing VTE in the community, it was clear, that she was at very high risk of developing VTE. It was also noted that she should have had a VTE risk assessment on admission, in accordance with NICE guidelines; where all acute psychiatric inpatients should have this assessed as soon as possible.ConclusionThrough a process of assessment and treatment, VTE is often preventable. Identification of high-risk patients on admission to hospital is therefore crucial. It is thus, imperative that a comprehensive VTE risk assessment is completed on admission and regularly reviewed.This case highlights the risk of missing VTE assessments in WAA Inpatients, particularly those with catatonia, about to undergo ECT, which could have been fatal. As such, VTE/PE risk assessment in such patients, about to undergo ECT, is particularly crucial.Clinicians need to have a high index of suspicion of VTE/PE, particularly in patients with catatonia.

Idiopathic Spontaneous Pneumomediastinum

A 25-year-old Singaporean male presented to the emergency department with sudden throat and chest pain. He had no known past medical or surgical history and was not on any chronic medications or supplementations. He was a lifelong nonsmoker and did not use recreational drugs. His throat pain started while he was eating dinner and was associated with dysphagia, odynophagia with both liquids and solids, and rhinolalia. His chest pain was pleuritic in nature and was not associated with any shortness of breath or diaphoresis.

Combined management of esophagopericardial fistula sustained after catheter ablation for atrial fibrillation

Radiofrequency ablation (RFA) is an effective treatment modality for atrial fibrillation (AF); however, serious complications can occur. We present the case of a highly morbid consequence, the esophagopericardial fistula (EPF). A hemodynamically unstable patient with a history of AF and recent RFA presented with chest pain and was found to have pneumopericardium and pericardial effusion. The patient went to the operating room emergently for combined management with surgical pericardial window and endoscopic stent placement. EPF must be on the differential diagnosis while evaluating patients who develop constitutional symptoms or sudden onset chest pain days or weeks after catheter ablation for AF. Early detection followed by aggressive management with a combined surgical and endoscopic approach may be considered for successful treatment of this type of postablation esophageal perforation if an atrioesophageal fistula is effectively ruled out.

Diagnostic findings in patients with chest pain, cough, and shortness of breath during the COVID-19 pandemic: what else besides pneumonia?

Purpose. Description and illustration of the most common alternative causes of shortness of breath, cough, and acute chest pain in pandemic COVID-19 conditions. Material and methods. Authors evaluated results of the retrospective single-center study and instrumental data of 67 patients with complaints of sudden chest pain, cough and shortness of breath. For patients admitted to the hospital between March, 27 and June, 30, 2020, the first stage of diagnosis was made with the performed multispiral computed tomography (MSCT) of the chest, confirming the presence of pulmonary manifestations of COVID-19. The study did not include patients with pneumothorax identified at the pre - and hospital stages. We describe early radiographic changes in the chest organs, main vessels, and coronary bed in patients with CT-confirmed COVID-19 admitted to O.M. Filatov Municipal Clinical Hospital No. 15, Moscow for sudden chest pain, cough, and shortness of breath. Results. In CT of the chest organs, combinations of COVID-19 and pulmonary artery thromboembolism, central/peripheral lung cancer, and acute aortic syndrome manifestations were most common. Combinations of radiation techniques in pandemic settings are COVID-19 required by patients with the acute coronary syndrome. However, it will be possible to analyze all cases of a combination of acute chest pain and sudden shortness of breath in patients with COVID-19 only after processing an extensive array of data. Conclusion. In pandemic conditions, COVID-19 performing standard imaging methods should be not lost about the most frequent causes of chest pain and sudden shortness of breath, complementing native MSCT with contrasting enhancement in suspected pathology of the main arteries, and small circulation in high-risk patients.

A128 ACUTE GASTRIC VOLVULUS DISGUISED AS ACUTE CORONARY SYNDROME.

Abstract Background Acute gastric volvulus is a rare but potentially life-threatening condition that warrants emergent assessment. Its clinical presentation may encompass the Borchardt’s triad of vomiting, epigastric pain, and inability to insert a nasogastric tube. However, it can also present as chest pain and is often not cited within the typical differential diagnosis of non-cardiac causes of chest pain. We report the first known case of mesenterico-axial gastric volvulus presenting as acute coronary syndrome with a normal electrocardiogram, complete with radiographic and endoscopic images. Aims To present a case of acute gastric volvulus disguised as an acute coronary syndrome and describe its management. Methods Case report and review of literature. Results A 68 year-old female with history of recent coronary artery bypass graft surgery presented to hospital with sudden onset chest pain radiating to her left shoulder and jaw while having dinner. Initial high sensitivity troponin (normal <9ng/L) was 15ng/L, which increased to a modest peak at 115ng/L. ECG at presentation and through admission consistently showed normal sinus rhythm x 5. She was assessed by Cardiology and given her rising troponin and chest pain, she was treated as a non-ST elevation myocardial infarction with dual antiplatelet therapy. She underwent cardiac catheterization showing distal graft anastomotic site stenosis and was stented x2. Post procedure, her severe retrosternal chest pain recurred. GI was consulted for dysphagia and odynophagia, which was then noted to be present concurrent with her initial chest pain presentation. An urgent CT scan of the abdomen and pelvis revealed acute mesenterico-axial gastric volvulus (Figure 1A), a rarer form of gastric volvulus in the adult population compared to its organo-axial counterpart. After a failed nasogastric decompression, an emergent upper endoscopy was attempted and demonstrated mucosal necrosis (Figure 1B) but was unsuccessful in relieving the volvulus. The patient then underwent overnight surgery, which showed gastric volvulus with contained perforation and 50% necrosis of the stomach with sparing of the cardia and antrum. This resulted in a subtotal gastrectomy, hiatus hernia repair, pyloromyotomy, jejunostomy, and bilateral chest tube insertion. She then recovered in ICU before being successfully discharged home from hospital. Conclusions Acute gastric volvulus can present while disguised as more common causes of chest pain, such as acute coronary syndrome. Those who present with chest pain who also have a history of a large hiatal hernia, or an intrathoracic stomach should be evaluated with gastric volvulus in the differential diagnosis as its prompt management is critical to reduce morbidity and mortality. Funding Agencies None

Ventricular Tachycardia as the Initial Presentation of Missed Kawasaki Disease in a Teenager

Introduction: Ventricular Tachycardia (VT) can be a life threatening condition and is not typically seen in otherwise healthy children. We report the first case, to our knowledge, of an otherwise healthy teenager with sustained VT as the presenting symptom for missed Kawasaki Disease (KD). Case presentation: A 14 year old, healthy male was brought by ambulance to the emergency department due to sudden onset chest pain and palpitations at rest. Physical exam revealed an oriented, conversant teen without murmurs, crackles or hepatomegaly. His EKG demonstrated wide complex tachycardia with a right bundle branch block morphology and superior axis at a rate of 213 bpm (Figure 1) consistent with VT from the left ventricle. He was an active soccer player with no prior history of palpitations, chest pain, syncope, recent illness or illicit drug use. Two doses of adenosine were administered without effect. A limited echocardiogram revealed normal appearing systolic function in the setting of tachycardia. The possibility of Belhassen’s VT, a rare but typically benign form of VT that is responsive to calcium channel blockers and most commonly seen in otherwise healthy teenagers, was considered. Two doses of Verapamil were administered without effect. Next, concern arose for papillary muscle VT. Two boluses of lidocaine were administered without effect. During an IV bolus of sotalol he became unresponsive and hemodynamically unstable requiring a synchronized cardioversion to restore sinus rhythm. A complete echocardiogram in sinus rhythm demonstrated dilated coronary arteries (CA), regional wall motion abnormalities and low normal function concerning for KD. Extensive questioning for history of possible KD was negative. However, CT imaging demonstrated mild diffuse right CA dilation with multiple focal aneurysms, a large, calcified left main CA aneurysm impinging on the LAD origin, and a diffusely hypoplastic left circumflex CA with restricted flow (Figure 2), and cardiac MRI revealed dilated and aneurysmal proximal CAs and a large transmural infarct of the basal anterior and anterolateral left ventricle, consistent with a remote history of KD. His VT was determined to be secondary to scar associated with infarct. He underwent an implantable loop recorder placement (family refused an ICD) and was discharged home on beta blocker and anticoagulation therapy. Discussion: KD is a well described ailment of childhood known to cause a vasculitis preferentially affecting the coronary arteries. With prompt and appropriate treatment, outcomes are favorable; however, when not recognized, patients may develop serious sequelae secondary to CA aneurysms. This is the first case of VT as the presenting symptom for missed KD in a teenager, increasing our knowledge of KD presentation and should also remind clinicians to broaden the differential diagnosis in new onset ventricular tachycardia.

Takotsubo stress cardiomyopathy following explantation of sEEG electrodes.

ObjectiveTakotsubo stress cardiomyopathy is characterized by dysfunction of the left ventricle of the heart including apical ballooning and focal wall‐motion abnormalities. Although reported in association with seizures and intracerebral hemorrhage, there are no studies reporting its occurrence in patients having stereoelectroencephalography (sEEG).MethodsA 38‐year‐old lady with no prior history of cardiac disease experienced sudden onset chest pain and acute left ventricular failure 4 hours following explantation of stereoelectroencephalogram electrodes.ResultsA small parenchymal hematoma related to the right posterior temporal electrode had been noted postelectrode insertion but was asymptomatic. Focal‐onset seizures from nondominant mesial temporal structures were recorded during sEEG. Following the presentation with LVF, new‐onset anterolateral T‐wave inversion with reciprocal changes in leads II, III, and aVF was noted on electrocardiogram (ECG) and the chest X‐ray findings were consistent with pulmonary edema. Echocardiography demonstrated hypokinesis of the cardiac apex and septum consistent with Takotsubo stress cardiomyopathy.SignificanceAwareness of the possible complication of Takotsubo stress cardiomyopathy is required in an epilepsy surgery program.

Sudden Chest Pain Due to Esophageal Intramural Dissection

Sudden Chest Pain Due to Esophageal Intramural Dissection

A death due to acute aortic dissection

Acute aortic syndrome (AAS) is a term used to describe a collection of life-threatening aortic disease conditions that have similar presentations, but differ in their demographic, pathological, clinical and other characteristics. The exact number of deaths due to AAS is unknown. However studies suggest that the majority of deaths in AAS are due to acute aortic dissection. A 51-year-old male developed sudden onset chest pain while he was taking a bath in the evening. It was a sharp, tearing type chest pain, which was radiating to the left side of his neck. On admission to hospital his low blood pressure was found to be low. He suffered cardiac arrest a few minutes later and died without regaining consciousness. Post-mortem examination revealed a massive haemopericardium (600 ml). Aortic dissection was identified extending from the aortic root to the lower part of the descending abdominal aorta. The thickest point of the dissection was 1.5 cm. There was an intimal tear inferiorly. The dissection extended through the aortic arch to the descending aorta ending 1 cm above the renal artery branching point. Sections of the aorta showed cystic medial degeneration with prominent pools of mucin. Mild atheroma was seen in some sections. The presence of aortic dissection was confirmed. The cause of death was given as haemopericardium due to ruptured aortic dissection. Acute aortic dissection may mimic other cardiovascular conditions, especially ischemic cardiac events. Therefore, the clinical suspicion and a comprehensive history-taking are the key for an early diagnosis. Careful dissection of the aorta and its branches is essential when making a post-mortem diagnosis of aortic dissection. Proper histopathology examination of the aorta assisted immensely in confirming the diagnosis.

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.