emergency medicine iceland

Sep 12, 2014

Young female with retrosternal pain and fever

Following is a case of a disease not so commonly encountered but worth knowing because of a concerning presentation - chest pain.

A female presents to the emergency department with a two day history of epigastrial pain. The pain is located right under the xiphoid process, and described as a sharp pain radiating through her chest and to the back. The pain is constant and worsens while lying on her back, on deep inhalation and when she eats or drinks. Lying on her left side alleviates the pain somewhat.

Her previous medical history includes Darier's disease (time to freshen up on your dermatology) and gastritis. Medications include Hydroxyzine (Atarax), oral contraceptive pill and isotretinoin (Accutane).

On examination there are no major clues as to her condition. Normal examination of lung­ and heart. Abdomen is non­distended, soft without guarding but diffuse tenderness mostly in the upper region. Bedside ultrasound shows no pericardial effusion, contraction is seen as normal and no signs of hypo- or akinesia. Gallbladder is not distended and no calculi are found. ECG is evaluated as normal with sinus rhythm, minimal inferolateral ST depressions and T ­inversions - concluded as nonspecific in the current clinical scenario. In the tachycardic patient with dyspnea pulmonary embolism could have been suspected.

Blood tests reveal slightly elevated CRP at 54 but other tests normal, Troponin T and d-dimer included. Chest x-ray is normal.

The morning after she develops fever 39°C. A trial of Gaviscon and Xylocain is unsuccessful. Augmentin 1,2g IV is administered empirically. On day three a gastroscopy is performed revealing multiple small, white, indented lesions in the esophagus. Candida infection is suspected and samples taken for PAD. CLO test is negative. She is suspected to have candida infection and admitted for treatment. The fever spikes occasionally up to 39.0°C but spontaneously resolves.

What do you think is causing retrosternal pain and fever in this young female?

Results come back from PAD and virology, surprisingly revealing an active infection with Herpes Simplex 1 (PCR positive). Other common causes of infectious esophagitis are candida and cytomegalovirus (CMV) and their presentation is similiar, requiring endoscopy for definite diagnosis.

A rare presentation for the above condition has been described where patient presented with intractable hiccups.

How are persistent hiccups defined and what are other important ddx to consider?

Hiccups for >48h are true 'persistent hiccups'. Many etiologies have been described but scaring ED physicians the most is the patient with ACS presenting as hiccups, it's been documented with several cases - enough for the lawyers to recognize it and the media to write about it. [Huffington Post 2012] Hiccups Were Patient's Only Heart Attack Symptom [Am J Emerg Med 2012] Hiccups as the only symptom of non-ST-segment elevation myocardial infarction

There are many treatment options and surely you should try rectal massage before pushing in that chlorpromazine!

Further reading

eMedicine has an extensive and excellent review as always [eMedicine] Esophagitis Amal Mattu as ever brilliant in his weekly ECG episodes, this time reviewing ECG findings in pulmonary embolism, do not start seeing patients in the ED until you have seen this! [Amal Mattu] ECG findings in pulmonary embolism

Authors: JMÆ/DBT

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