Chest Pain and Sudden-Onset Paraplegia at the Emergency Department: An Uncommon Presentation

Abstract Background Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism. Case series Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis. Methods To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital’s electronic medical record system to reassess all consecutive adult chest pain patients. Results The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71–553.37], twenty times higher than suggested by prevalence data. Discussion In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain. Conclusion Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction.

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Endometriosis: An Unusual Cause of Bilateral Pneumothoraces

Clinical Practice and Cases in Emergency Medicine ◽

10.5811/cpcem.2019.11.45061 ◽

2020 ◽

Vol 4 (1) ◽

pp. 35-37

Author(s):

Christopher Sampson ◽

Kathleen White

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Respiratory Distress ◽

Chest Radiograph ◽

Spontaneous Pneumothorax ◽

Sudden Onset ◽

Shortness Of Breath ◽

Pelvic Endometriosis ◽

Catamenial Pneumothorax

A 27-year-old female presented to the emergency department with sudden onset shortness of breath. A diagnosis of bilateral catamenial pneumothoraces was made following chest radiograph. Catamenial pneumothorax is a recurrent spontaneous pneumothorax that occurs in 90% of affected women 24-48 hours after the onset of their menstruation; 30-50% of cases have associated pelvic endometriosis. Symptoms can be as simple as chest pain or as severe as the presentation of this patient who was initially found to be in significant respiratory distress.

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Spontaneous Sternal Fracture — A Misnomer

Journal of the Royal Society of Medicine ◽

10.1177/014107688607900316 ◽

1986 ◽

Vol 79 (3) ◽

pp. 175-176 ◽

Cited By ~ 2

Author(s):

R C Bowyer ◽

V L R Touquet

Keyword(s):

Myocardial Infarction ◽

Emergency Department ◽

Pulmonary Embolism ◽

Chest Pain ◽

Sudden Onset ◽

Sternal Fracture ◽

Uncomplicated Case ◽

Accident And Emergency ◽

Accident And Emergency Department ◽

Sternal Fractures

Spontaneous sternal fractures, although rare, may present to the Accident and Emergency Department as a severe central chest pain of sudden onset. These may be confused with myocardial infarction1 or pulmonary embolism2. Treatment in the uncomplicated case may be symptomatic with analgesics, but this fracture may require sternal wiring if paradoxical sternal movement embarrasses respiration. Spontaneous fracture of the sternum appears in the majority of cases to be due either to secondary metastatic infiltration, myelomatosis or extreme osteoporosis3. We report a case which emphasizes the importance of investigating these patients.

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Transient binocular blindness: A rare presentation of aortic dissection

Hong Kong Journal of Emergency Medicine ◽

10.1177/1024907918816575 ◽

2018 ◽

Vol 27 (4) ◽

pp. 236-240

Author(s):

Abdul Hafiz Shaharudin ◽

Muhamad Hafiq Ab Hamid ◽

Rosliza Yahaya ◽

Nik Ahmad Shaiffudin Nik Him ◽

Nik Arif Nik Mohamed ◽

...

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Carotid Artery ◽

Aortic Dissection ◽

Sudden Onset ◽

Rare Presentation ◽

Diagnostic Dilemma ◽

Threatening Condition ◽

Life Threatening ◽

High Index Of Suspicion

Introduction: Aortic dissection is a clinical chameleon that can have variable presenting features that require a careful history and physical examination. A non-specific presentation of this life-threatening condition causes a diagnostic dilemma among clinicians especially in the emergency department leading to grave consequences. Case Presentation: We present a case of aortic dissection that presented as an acute bilateral blindness that was associated with a sudden onset of loss of consciousness and central chest pain. Bedside carotid ultrasound showed a double lumen carotid artery suggesting an intraluminal flap. Computed tomography angiography revealed extensive dissection of the entire length of the aorta. Discussion: This case illustrated the need for a high index of suspicion to diagnose patients with aortic dissection especially as the patient presented with an acute binocular visual loss and chest pain. Conclusion: A bedside carotid artery ultrasound in the emergency department was found useful in screening and diagnosing a carotid artery–related pathology.

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ERRATA

PEDIATRICS ◽

10.1542/peds.84.3.582a ◽

1989 ◽

Vol 84 (3) ◽

pp. 582-582

Author(s):

Steven M. Selbst

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Cocaine Abuse ◽

Coronary Artery Spasm ◽

Sudden Onset ◽

Drug Screen ◽

Severe Chest Pain ◽

Drug History ◽

One Year ◽

Physical Findings

In a Letter to Editor (Pediatrics 1989;83(suppl):639-640) the following letter was misprinted and it is repeated here. CHEST PAIN IN AN ADOLESCENT: THINK OF COCAINE! We appreciate Dr. Schwartz' thoughtful comments about our article. Our failure to mention cocaine abuse in the discussion of chest pain was an oversight. previously, I reported the case of an adolescent who presented to our Emergency Department with acute, severe chest pain from cocaine abuse. This teenager presented long after completion of our study of 407 children with chest pain, even after our manuscript was first drafted. We were surprised by his presentation, and by the fact that no others like him had presented during our one year study period. I think it is unlikely that we missed any cocaine abusers in our group of patients with "idiopathic" chest pain. As noted previously, cocaine can cause tachycardia, pneumothorax, hypertension, and coronary artery spasm with myocardial infarction. Thus, those with subsequent chest pain will undoubtedly have acute, severe chest pain and physiologic changes. These children would have been evaluated in our Emergency Department with electrocardiograms and further studies. I agree that a drug history and toxicologic screening for cocaine abuse should be obtained for all adolescents with severe chest pain of sudden onset. This should even be considered for some younger children as drug abuse has become more widespread in our society. However, I do not think a drug screen is indicated for all children with idiopathic chest pain, especially if their pain is chronic and the physical findings are normal.

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