A 78-year-old woman was admitted to her local hospital for hematemesis. Her past medical history included arterial hypertension, right leg phlebitis, carotid atheroma (right carotid stenosis: 70%), early Alzheimers Disease and allergy to ASA and NSAIDs. She had a 3 cm right breast cancer (C5) of recent diagnosis and she was dysphagic for some weeks. The physical examination showed severe clinical conditions, signs of heart failure and a nodule with skin retraction in the inferior and central area of the right breast; there were no signs of subcutaneous emphysema or peritonitis. Her labs showed WBC max 39600/mcl, RCP >25 mg/dl, BNP 1040 pg/ml and a hypokalaemia (K+ 2,5 mEq/L) supported by a non-compensated metabolic alkalosis. She underwent an abdominal X-ray imaging, which excluded intestinal perforation or obstruction, but found a left lung consolidation with left pleural effusion, and an EGDS, which showed an abnormal morphology of the cervical oesophagus wall, compatible with infiltrant malignancy causing luminal stenosis (ab extrinseco?); the stomach and duodenum appeared normal, with a very small quantity of blood. The patient was admitted to the surgery department and an antibiotic and diuretic therapy was set. On her first day of hospital stay she had further episodes of hematemesis and was symptomatic for dyspnoea and chest pain, which was responsive to sublingual nytroglicerine; her vital parameters were steady (BP 160/100 mmHg, HR 100 bpm, SaO2 97% with O2 2 L/min, active diuresis), blood troponin was 0,05 ng/ml and the serial ECGs performed showed modifications, with occurrence of sinus arrhythmia, QTc 476 msec, negative T waves in inferior leads, biphasic T waves in precordial leads and diffuse, aspecific ventricular repolarization abnormalities. For this reason the internist was asked to consult: in agreement with the surgeon, on the basis of the patients clinical history and the elements available until then, an urgent chest and abdomen TC scan was performed. The imaging study revealed a ruptured aortic arch aneurysm with extraluminal para-aortic contrast blush and a large mediastinal hematoma compressing and shifting the oesophagus and the tracheal lumen airway, pre-stenotic oesophageal achalasia with a gas-fluid level compatible with aorto-oesophageal fistula; other findings were a saccular infrarenal abdominal aortic aneurysm, a right breast neoformation of 30 mm diameter and irregular margins, a left pleural effusion with small postero-basal bands of atelectasis and cardiomegaly. The clinical conditions got worse and the patient died on her second day of hospital stay. This is an exemplary case of dyspnoea and chest pain of multiple aetiology in a critical patient, requiring multidisciplinary evaluation, both surgical and internistic.
A case of dyspnoea and chest pain: which is the diagnosis?
Falsetti LorenzoWriting – Review & Editing
;
2015
Abstract
A 78-year-old woman was admitted to her local hospital for hematemesis. Her past medical history included arterial hypertension, right leg phlebitis, carotid atheroma (right carotid stenosis: 70%), early Alzheimers Disease and allergy to ASA and NSAIDs. She had a 3 cm right breast cancer (C5) of recent diagnosis and she was dysphagic for some weeks. The physical examination showed severe clinical conditions, signs of heart failure and a nodule with skin retraction in the inferior and central area of the right breast; there were no signs of subcutaneous emphysema or peritonitis. Her labs showed WBC max 39600/mcl, RCP >25 mg/dl, BNP 1040 pg/ml and a hypokalaemia (K+ 2,5 mEq/L) supported by a non-compensated metabolic alkalosis. She underwent an abdominal X-ray imaging, which excluded intestinal perforation or obstruction, but found a left lung consolidation with left pleural effusion, and an EGDS, which showed an abnormal morphology of the cervical oesophagus wall, compatible with infiltrant malignancy causing luminal stenosis (ab extrinseco?); the stomach and duodenum appeared normal, with a very small quantity of blood. The patient was admitted to the surgery department and an antibiotic and diuretic therapy was set. On her first day of hospital stay she had further episodes of hematemesis and was symptomatic for dyspnoea and chest pain, which was responsive to sublingual nytroglicerine; her vital parameters were steady (BP 160/100 mmHg, HR 100 bpm, SaO2 97% with O2 2 L/min, active diuresis), blood troponin was 0,05 ng/ml and the serial ECGs performed showed modifications, with occurrence of sinus arrhythmia, QTc 476 msec, negative T waves in inferior leads, biphasic T waves in precordial leads and diffuse, aspecific ventricular repolarization abnormalities. For this reason the internist was asked to consult: in agreement with the surgeon, on the basis of the patients clinical history and the elements available until then, an urgent chest and abdomen TC scan was performed. The imaging study revealed a ruptured aortic arch aneurysm with extraluminal para-aortic contrast blush and a large mediastinal hematoma compressing and shifting the oesophagus and the tracheal lumen airway, pre-stenotic oesophageal achalasia with a gas-fluid level compatible with aorto-oesophageal fistula; other findings were a saccular infrarenal abdominal aortic aneurysm, a right breast neoformation of 30 mm diameter and irregular margins, a left pleural effusion with small postero-basal bands of atelectasis and cardiomegaly. The clinical conditions got worse and the patient died on her second day of hospital stay. This is an exemplary case of dyspnoea and chest pain of multiple aetiology in a critical patient, requiring multidisciplinary evaluation, both surgical and internistic.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
