Malays Fam Physician 14(1): 47-52

Pleuritic chest pain and fever: An unusual presentation of aortic dissection

Case

A 63-year old gentleman presented to our primary care clinic with a two-day history of sudden-onset central chest pain at rest which radiated up to his neck. It was sharp in nature and worse on inspiration. He felt feverish but had neither a cough nor dyspnoea. His pain had been constant, with a score of 7 out of 10. Paracetamol relieved his fever but not the pain. There was no haemoptysis, calf pain, history of immobility, or trauma to his chest. He was on perindopril for hypertension and atorvastatin for dyslipidaemia. He quit smoking seven years ago and did not use any recreational drugs.

Clinically, he looked well and was not tachypnoeic. His oral temperature was 38.3°C, oxygen saturation was 97% on air, respiratory rate was 14 breaths per minute, blood pressure was 135/78 mmHg, and pulse was regular at 95 beats per minute, with no radio-radial delay. On auscultation, his heart sounds were normal. There were equal vesicular breath sounds in the bilateral lung fields. There was no calf swelling or tenderness bilaterally. Examination of other systems, including neurological examinations, were normal.

His electrocardiogram (ECG) did not show any abnormality. A chest X-ray was performed, and it showed no significant abnormality (Figure 1). The following blood tests were ordered: full blood count (FBC), C-reactive protein (CRP), renal profile (RP), liver function tests (LFT), and Troponin T (Trop T).

An external file that holds a picture, illustration, etc.
Object name is MFP-14-47-g1.jpg

Figure 1.

Chest radiograph (PA erect) is normal with no widened mediastinum (normal <7.5cm) or double aortic contour.

At this point in time, the differential diagnosis considered was early atypical pneumonia given the pleuritic nature of the pain and fever. An atypical presentation of acute coronary syndrome (ACS) was also considered in view of his cardiovascular risk factors.

He was given paracetamol and kept for observation while waiting for his investigation results. An hour later, the laboratory investigations showed an elevated Trop T of 22 (Normal<14 ng/L), white cell count (WCC) of 13.11 × 10³ (4.0–10.0 × 10^{/µL), neutrophilia of 10.37 × 10}³ (1.9–8 × 10³/µL), and a CRP of 112.9 (<5.0 mg/L).

Upon discussion with the cardiologist on duty, the patient was admitted for observation with a plan to repeat an ECG and troponin in six hours. Oral antibiotics with atypical pneumonia coverage were given. Upon review, his symptoms settled, and the repeat ECG and troponin were normal. He was discharged with a course of oral antibiotics, a review appointment in three days, and appropriate safety netting.

He returned to the emergency department two days later with a similar persistent pain, lethargy, and feelings of feverishness. His temperature and other vital signs were normal, and there were right basal crackles on auscultation of his lungs. This time, his ECG (Figure 2) showed non-specific changes (widespread ST elevation on leads I, II, V2–V6; ST depression on leads aVR and V1). Repeat blood tests, including for troponin, and blood cultures were normal except for an elevated CRP (334 mg/L). A transthoracic echocardiogram was performed and showed mild global pericardial effusion with a left ventricular ejection fraction of 48%.

An external file that holds a picture, illustration, etc.
Object name is MFP-14-47-g2.jpg

Figure 2.

ECG on second presentation shows widespread ST elevation on leads I, II, V2-V6; ST depression on leads aVR and V1.

The working diagnosis at this point was community-acquired pneumonia with acute pericarditis. He was started on intravenous ceftriaxone and oral ibuprofen. His symptoms did not improve after two days of treatment; hence, a CT thorax was performed to investigate further.

The CT thorax showed a dilated ascending aorta with possible dissection. Thus, a CT aortogram was subsequently performed. This aortogram showed a Stanford A ascending AD (Figure 3). He was admitted to intensive care for strict pulse and blood pressure control.³,4 The cardiothoracic surgical team repaired the ascending aorta surgically using an open approach, while the descending aorta was managed using a stent-graft.⁵ The patient recovered well post-operatively and was discharged after five days. He was reviewed in the outpatient clinic after 6 months and has continued to do well.

An external file that holds a picture, illustration, etc.
Object name is MFP-14-47-g3.jpg

Figure 3.

Axial CT aortogram. The ascending aorta (circled) is dilated and measures 4.6cm in diameter (normal 3.5cm). An intimal flap (black arrow) divides the aortic lumen into a true lumen (black arrowhead) and a false lumen which is partially thrombosed (white arrowhead). A normal descending thoracic aorta is seen posteriorly (*).

Summary

AD should be considered in all patients with atypical chest pain. It may present with fever and elevated CRP. Pulse or blood pressure differentials, hypotension, and neurologic deficits can be helpful in terms of suggesting aortic dissection, but their absence cannot rule out the diagnosis. The ADD-RS is a useful risk stratification tool for AD, and the combination of the ADD-RS and the D-dimer test is helpful in ruling out AD. However, the D-dimer test is not widely available in the Malaysian primary care setting. Therefore, patients with an ADD-RS score ≤ 1 should be referred for D-dimer testing in the secondary care setting.

“We declare that there are no competing interests and that no funding was received for this case study.

How does this paper make a difference to general practice?

The unusual presentation highlights the need for a heightened level of clinical suspicion of AD in the absence of classic features.
It highlights that:
- fever and elevated CRP are possible associated features of AD.
- the absence of classic features, such as pulse or blood pressure differentials, hypotension, and neurological deficits, does not rule out AD due the low sensitivity exhibited by these features.
- the ADD-RS is a useful tool for AD risk stratification.
- the combination of the ADD-RS and the D-dimer test is useful in ruling out AD.

MBBS (Monash), FRACGP, Department of Primary Care Medicine, Faculty of Medicine Universiti Teknologi MARA Selangor, Malaysia. Email: moc.liamg@nissay.firays

MBBS (Monash), FRACGP, Faculty of Medicine, Universiti Teknologi MARA, Selangor Malaysia.

MBBS (Newcastle, UK), MRCGP (UK), Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM) Universiti Teknologi MARA, Selangor Malaysia.

MBChB (TCD), MRad (UM), Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia.

MBBS (Monash), FRACGP, Department of Primary Care Medicine, Faculty of Medicine Universiti Teknologi MARA Selangor, Malaysia. Email: moc.liamg@nissay.firays

Abstract

It remains a challenge to diagnose aortic dissection in primary care, as classic clinical features are not always present. This case describes an atypical presentation of aortic dissection, in which the patient walked in with pleuritic central chest pain associated with a fever and elevated C-reactive protein. Classic features of tearing pain, pulse differentials, and a widened mediastinum on chest X-ray were absent. This unusual presentation highlights the need for a heightened level of clinical suspicion for aortic dissection in the absence of classic features. The case is discussed with reference to the literature on the sensitivity and specificity of the classic signs and symptoms of aortic dissection. A combination of the aortic dissection detection risk score (ADD-RS) and D-dimer test is helpful in ruling out this frequently lethal condition.

Keywords: Aortic dissection, aortic dissection detection risk score, chest pain, elevated C-reactive protein

Abstract

Acknowledgement

We would like to acknowledge Prof. Dr. Mohd Zaki Salleh for his valuable input into this case report.”

Acknowledgement

References

1. Hagan PG, Nienaber CA, Isselbacher EM, et al The International Registry of Acute Aortic Dissection (IRAD): New insights into an old disease. JAMA. 2000;283:897–903.[PubMed][Google Scholar]
2. Pape L, Awais M, Woznicki E, et al Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the International Registry of Acute Aortic Dissection. J Am Coll Cardiol. 2015;66(4):350–8. doi: 10.1016/j.jacc.2015.05.029.] [[PubMed][Google Scholar]
3. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for The Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC) Eur Heart J. 2014;35:2873–926. doi: 10.1093/eurheartj/ehu281.] [[PubMed]
4. Hiratzka LF, Bakris GL, Beckman JA, et al 2010 ACCF/AHA/AATS/ACR/ASA/SCA/ SCAI/SIR/STS/SVM Guidelines for The Diagnosis and Management of Patients with Thoracic Aortic Disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266–e369. doi: 10.1161/CIR.0b013e3181d4739e.] [[PubMed][Google Scholar]
5. Black JH, Manning WJ Management of acute aortic dissection. Waltham, MA: UpToDate Inc; [Feb 5;2018 ]. Available at. Accessed. [PubMed][Google Scholar]
6. Ohle R, Kareemi HK, Wells G, et al Clinical examination for acute aortic dissection: A systematic review and metaanalysis. Acad Emerg Med. 2018;25:398–412.[PubMed][Google Scholar]
7. Shimada S, Nakamura H, Kurooka A, et al Fever associated with acute aortic dissection. Circ J. 2007;71:766–71.[PubMed][Google Scholar]
8. Geppert AG, Mahvi A, Hainaut P, et al Chronic aortic dissection masquerading as systemic disease. Acta Clin Belg. 1998;53:19–21.[PubMed][Google Scholar]
9. Dai MS, Cheng SMAortic dissection presenting as fever of unknown origin. Acta Cardiol. 2001;56:37–38. doi: 10.2143/AC.56.1.2005591.] [[PubMed][Google Scholar]
10. Turner N, Pusey CDAortic dissection masquerading as systemic disease: The post dissection syndrome. QJ Med. 1990;75:525–31.[PubMed][Google Scholar]
11. Hirst AE, Johns VJ, Kime SWDissecting aneurysm of the aorta: A review of 505 cases. Medicine. 1958;37:217–79. doi: 10.1097/00005792-195809000-00003.] [[PubMed][Google Scholar]
12. Garcia-Romo E, Lopez-Medrano F, Llovet A, et al Fever due to inflammation in acute aortic dissection: Description and proposals for diagnostic and therapeutic management. Rev Esp Cardiol. 2010;63(5):602–6.[PubMed][Google Scholar]
13. Eggebrecht H, Naber CK, Bruch C, et al Value of plasma fibrin D-dimers for detection of acute aortic dissection. J Am Coll Cardiol. 2004;44:804–9. doi: 10.1016/j.jacc.2004.04.053.] [[PubMed][Google Scholar]
14. Sbarouni E, Georgiadou P, Marathias A, et al D-dimer and BNP levels in acute aortic dissection. Int J Cardiol. 2007;122:170–72. doi: 10.1016/j.ijcard.2006.11.056.] [[PubMed][Google Scholar]
15. Luo F., Zhou X.L., Li J.J., Hui R.TInflammatory response is associated with aortic dissection. Ageing Res Rev. 2009;8:31–35. doi: 10.1016/j.arr.2008.08.001.] [[PubMed][Google Scholar]
16. Schillinger M, Domanovits H, Bayegan K, et al C-reactive protein and mortality in patients with acute aortic disease. Intens Care Med. 2002;28:740–45.[PubMed][Google Scholar]
17. Wells PS, Anderson DR, Rodger M, et al Excluding pulmonary embolism at the bedside without diagnostic imaging: Management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135:98–107.[PubMed][Google Scholar]
18. Nazerian P, Mueller C, Soeiro AM, et al Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: The ADvISED prospective multicenter study. Circulation. 2018;137(3):250–58. doi: 10.1161/CIRCULATIONAHA.117.029457.] [[PubMed][Google Scholar]
19. Diercks DB, Promes SB, Schuur JD, et al Clinical policy: Critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015;65:32–42. e12. doi: 10.1016/j.annemergmed.2014.11.002.] [[PubMed][Google Scholar]