Case Report: A 34-year-old male with radiating chest pain

Aug 07, 2019

A 34-year-old male with no significant past medical history presents to the emergency department with 10 hours of constant chest pain radiating into his back that started last night. What's your diagnosis?

A 34-year-old male with no significant past medical history presents to the emergency department with 10 hours of constant chest pain radiating into his back that started last night. The pain is not severe unless he lies down or completely empties his lungs of air. Because of this, he had to sleep sitting up. He denies any fever, shortness of breath, cough, symptoms in his arms or legs or other complaints.

Exam:  Vital signs are normal. The physical exam is completely normal including auscultation of the heart and lungs. Specifically, pulses are symmetric and there is no chest or calf tenderness.

Initial differential diagnosis:

  • Aortic dissection

  • Pericarditis

  • Pulmonary Embolism

  • Acute Coronary Syndrome

EKG read (see image on the right):

  • NSR with sinus arrhythmia

  • Normal EKG

Do you agree with the read?

NEXT PAGE:  Answer

EKG Analysis:  The cread is correct but incomplete. Not noted but present is fairly diffuse mild concave-up ST elevation. This could certainly be benign early repolarization, but without a baseline EKG and subsequent EKGs for comparison, it could be pericarditis as well. Further testing was done.

Case Conclusion:  Since the patient’s pain radiated to the back, a CTA of the chest was ordered to assess for aortic dissection. The CT did not show a dissection, but did show a sliver pericardial effusion (see image on the right with arrow pointing to effusion. Remember on CT that fat and air are black, but fluid is gray (this is very different from echo). While in the emergency department, the patient actually developed a pericardial friction rub.  Although dissection was not present in this case, it is actually one of the known causes of pericarditis. (Reviewed by Dr. Stephen W. Smith of Dr. Smith’s ECG Blog.)

DISCUSSION:  Pericarditis typically presents clinically with midsternal chest pain that is often pleuritic, radiates to the back or trapezius and is worse supine and/or with breathing or swallowing. The pleuritic component may triggered by expiration rather than inspiration, as in this case. The physical exam is usually normal, although a friction rub is occasionally heard

Testing in pericarditis should always include an EKG, chest x-ray and troponin-i. An EKG will be abnormal in only about 70 percent of cases of pericarditis. Typical early findings include PR depression and diffuse concave-up ST elevation. Later stage EKG findings in pericarditis are listen in the page shot to the right. When the pain is pleuritic in nature a d-dimer is often ordered and is not infrequently positive. If so, CT may be more useful than VQ because CT may show a pericardial effusion and can also be used to rule our aortic dissection, one of the most dangerous causes of pericarditis. Troponin will be elevated in about a third of cases and is thought to signify concomitant myocarditis.

There are many causes of pericarditis, such as aortic dissection, idiopathic causes or constrictive pericarditis. The most common etiology is idiopathic. Treatment of pericarditis is tailored to the suspected primary cause. For idiopathic pancreatitis, colchicine is the treatment of choice and should be continued for three months. See the Emergency Medicine 1-Minute Consult Pocketbook for indications for hospitalization.

Case lessons:  

  • The EKG is only ~70% sensitive for pericarditis.  It is more likely to miss milder or earlier cases.

  • Not everyone with pericarditis needs a CT of the chest, but when there is concern for pulmonary embolism or aortic dissection, CT can evaluate for both.