A deadly case…can you figure it out before the autopsy?

18 Jan

Hi everybody, welcome back on EMDutch. As promised I am working on “diuretics in AHF” right now. To be honest, it doesn’t seem to be the cornerstone of treatment in my mind, but that will be discussed in my next post. Because these CAT’s (“critical approved topics”) take a lot of time I thought it would nice to present a case for you today!
Every doctor in his career will encounter patients he or she will never forget. Sometimes because of their appearance, attitude or disease, but in this case it was the outcome……DEAD! And off course we often see people die in the ED. And off course you kind of get used to it. And off course it’s part of the job. But when an otherwise healthy men, 50 years of age, dies a couple of hours after you have seen him it tends to stick! Getting interested??? Just read the case below. Hopefully you will learn something from it and otherwise you can always e-mail/tweet/post me what a bad job I did! Please don’t scroll to the end, but test yourself and try to find what I missed, while reading the case!

So this 50 year old men was seen by one of my colleagues in the ED with acute onset of chest pain without radiation. He has hypertension in his medical history and had no prior episode of chest pain. He was hemodynamically stable. His ECG showed minimal ST-elevation in V2-V3 and an inverted T-wave in III and aVF. On the chest X-ray a slightly widened mediastinum was found which was explained by the technique of the photo. The cardiac enzymes were negative and he was admitted for chest pain with low molecule heparin and ASA.
The ergometric stress test showed no ischemic response and ultrasound of the heart showed a slighty widened aorta ascendens (44mm) and a bicuspid aorta valve. He developed abdominal pain with fever and an elevated WBC and CRP and was transferred to internal medicine. The abdominal ultrasound performed showed no pathology.
On the 3rd day he got a second episode of severe chest pain, which was almost gone when I came to take a look at the patient. I was in my first year and did my rotations in cardiology. Like with every chest pain patient in the house I was called to take a look at the patient. He looked fine and was hemodynamically stable. There were new changes on the EKG this time (see below). And because I was in Emergency Medicine I knew Amal Mattu (really, who doesn’t???)….and when you know him, you know EKG’s…and in this case pericarditis. The EKG showed ST-elevations in multiple leads, so I asked myself the 3 questions to differentiate between pericarditis and MI:
1.) Is there any ST-depression (beyond aVR & V1)  No (we can debate about lead III & aVF, but it was exactly the same as in the 1st EKG.)
2.) Is there ST-elevation covex upwards or horizontal  No
3.) ST-elevation III>II  No
THIS MEANS NO MI, IT MEANS PERICARDITIS!

ECG post EMDutch

SR, 65/min, 1st degree AV-block, concave ST elevation I, aVL, V2-V5, inverted T wave III, aVF and aVR

He got NSAID’s next to the antibiotics he already was given and his symptoms disappeared. But….In the 5th night the patient suddenly died.
So what did I miss? I had no idea! Was it a MI after all, was it a PE….or was it something else??? Well, it was something else! Autopsy showed an aortic dissection type A with massive hemopericardium.

So where did I go wrong and what were the clues I missed? In retrospect there were 3 (and if you more, please let me know!):
1.) 1 diagnosis is just 1 diagnosis, but maybe not the whole diagnosis. Pericarditis may present as a sudden sharp pain, but other causes like MI, PE, GERD and dissection has to be in your mind. It wasn’t in mine. I stopped at the 1st diagnosis! Boy, did I learn my lesson!
2.) In 1987 Saner He, et al (1) already describes 5 cases in which pericarditis was the 1st sign of aortic dissection (type A). The hypothesis is that slow pentration of blood into the pericardial space causes inflammation. It’s striking that 2 of these cases had a bicuspid aortic valve, just like our patient. Even before 1987 Edwards (in 1978) already describes the relation between dissection and bicuspid valve (2) In my defence….at the time I had no knowledge of this and it’s sad to figure this out when it’s too late for the patient.

3.) This patient had chest- and abdominal pain. So he had pain above and below the diaphragma. Like somebody recently told me (I know…too little too late!)….think dissection ! One article showed that in dissection 67% has chest pain, 84% had sudden onset of any pain and 23% had abdominal pain (and 64% has a history of hypertension !!!) (3)

In conclusion:
An aortic dissection is a difficult diagnosis to make. That’s why it is important to know it can initially present as a pericarditis. There is often a ‘therapeutic window of treatment’, which means you have time on your side to get to the correct diagnosis in time.
This case doesn’t justify a CT with every patient presenting in the ED with a pericarditis, but in retrospect our patients had some signs which could have led to the correct diagnosis. He had a widened mediastinum and a bicuspid aortic valve which is a known risk factor for aortic dissection. Futhermore he has chest- and abdominal pain !

Ok….hopefully you have enjoyed reading this case and remember….aortic dissection is ‘the great masquerader’ and you will miss some in your carreer, but maybe this can help you to find more aortic dissections in your carreer! Good luck!

Until next time !

Egon Zwets

References:
1.)
Chest. 1987 Jan;91(1):71-4.
Aortic dissection presenting as pericarditis.
Saner HE, Gobel FL, Nicoloff DM, Edwards JE.

2.)
Circulation. 1978 May;57(5):1022-5.
Dissecting aortic aneurysm associated with congenital bicuspid aortic valve.
Edwards WD, Leaf DS, Edwards JE.

3.)
JAMA. 2002 May 1;287(17):2262-72.
Does this patient have an acute thoracic aortic dissection?
Klompas M.

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8 Responses to “A deadly case…can you figure it out before the autopsy?”

  1. Mohsen Majidpour January 19, 2013 at 00:15 #

    Nice case Egon thanks for sharing.
    I have two questions. Was the first day desection not considered, there was still a little wide mediastinum seen on x-Raymond! and also on the ultrasound? Did you done ddimmer?

    The problem in the Netherlands health care systeme is that these patients are referred directly to cardiology and is there likely more chance for tunnel vision.

    • emdutch January 23, 2013 at 14:32 #

      Sadly a dissection was not the (and also not in my) differetial. I focussed to much on the pericarditis. Maybe because I just did a presentation on it at the time and I was to happy with my pericarditis. Since dissection and PE was not in the differential we had no D-dimer in this patient so fare I know. I will look it up and if a D-dimer was done I will let you know!

  2. Rahul Goswami (@Rahul_Goswami_) January 23, 2013 at 20:14 #

    We all have had one man. Dissections are our bane.
    1. Have to disagree with you – I would not call that ECG pericarditis. Not global and no PR depression.
    2. Was he hypertensive at any point? Thats usually the clue if not typical tearing pain.

    Rahul

  3. Michiel (@meddr) February 6, 2013 at 11:16 #

    Nice case and thanx for sharing.
    Having done a year internship in thoracic-surgery I’m aware of my extra knowledge…
    I think in retrospect the bicuspid valve could have been the trigger to the diagnosis… especially combining it with the slightly widened mediastinum on the x-ray and the slightly widened aorta ascendens on ultrasound. (The risk of aortic dissection in patients with a bicuspid valve is 5 to 9 times higher than in the general population. (Circulation.
    2005; 111: 832-834))
    But then again I’m not sure if I or one of my colleagues would have caught this one in my ED.

    Thanx for the inspiring site and cases!

  4. Michiel February 6, 2013 at 11:18 #

    Reblogged this on Mike’s Mobile Life and commented:
    nice case on the Dutch EM blog!

  5. Ryan May 5, 2014 at 18:36 #

    I would think that that ECG showed lateral STEMI?
    Pericarditis would not have that straight STE in V5-V6

  6. dave b December 18, 2016 at 01:34 #

    I see obvious ST Elevation in: lead I and lead II/aVL. Abnormal Upright T-waves in V1 which are taller than in V6: Ischemia, CAD/CVD. There are subtle notches/depression after most P-waves in V1-V3. T-waves are hyper acute in V2 & V3. Subtle U waves in leads II, aVL & lead III. P-wave morph in Lead II & III, & V5 & V6. Inverts in aVF.

    Trops, D-dimer and ultrasound/echo without a doubt just get it done. Bi lateral blood pressure results……….Hypo/hyper-tensive…………..Pain in chest/abdomen or palping abdomen………..Clammy, sweaty……..feverish………etc etc.
    Pericarditis is an infection and i’d say start with the absolute worst and rule all that out, then move towards infections etc. Ultrasound/echo would have shown a bicuspid valve which would have helped diagnosis. If suspected infection after 5 days of antibiotics still showed reoccurring signs acutely then again clear indication of other root cause. The fact there is ST elevation of any kind i’d say there is also infarc which may have aided in dissection.

    • dave b December 18, 2016 at 01:43 #

      Also what was the Pulse rate again? There is no arrhythmia, and it essentially shows perfect sinus rhythm with equal QRS width. I’d expect slight arrhythmia or palpitations with Pericarditis or other infections.

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