Aortic dissection is the most common life threatening disorder affecting the aorta, with a mortality rate as high as 50% within 48 hours, making its prompt recognition, diagnosis and treatment critical for survival.
We present a 59 year-old male with no past medical history who came in vague abdominal discomfort, vomiting, hematochezia, and a mid-sternal, pressure-like, non-radiating chest pain several hours after his meal. Examination was significant for bradycardia, and fine twitching in the neck and jaw, with equal blood pressure readings on both arms. Neurologic exam was normal. Labs showed elevated creatinine and Bilirubin, with normal troponin and chest x-ray. EKG showed sinus bradycardia. Patient was subsequently admitted to the CCU and underwent CT of abdomen and pelvis, revealing aortic dissection of the lower thoracic aorta with extension into the common iliac arteries. He was initially managed supportively but subsequently underwent a CT angiography of the chest, abdomen and pelvis which revealed a type A aortic dissection involving the right renal, mesenteric arteries, right common carotid, and left proximal internal carotid arteries, thus prompting emergent repair.
Aortic dissection classically presents as a sudden, severe chest pain with tearing or ripping quality associated with a significant inter-arm blood pressure differential and mediastinal widening on chest x-ray, in a patient with risk factors such as hypertension, trauma, syphilis, Marfan’s syndrome, Ehler-Danlos syndrome, bicuspid aortic valve. Our patient, in contrast, was a healthy male with no risk factors, who presented atypically with abdominal discomfort and pressure like chest pain following a meal. At a first glance, his symptoms could point to an alternate diagnosis, yet it is important to remember that aortic dissection, albeit common, has a highly variable presentation with a wide array of complaints mimicking common conditions. Our patient’s elevation in creatinine and hematochezia was likely due to the involvement of the renal and mesenteric arteries, and twitching of the neck and jaw was likely from the carotid involvement. Immediate management includes stabilizing the patient with prompt blood pressure reduction and emergent surgery for Type A dissections.
This case highlights the significance of having a high index of suspicion for aortic dissection in any patient who presents with sudden onset chest pain regardless of quality and absence of traditional risk factors. We often fall into early closure when patients present with common complaints, but we must not undermine the paramount importance of correlating a thorough history and physical examination and available data, to aid in the timely diagnosis and management of this treatable and reversible medical condition.
To cite this abstract:Mateo RCI, Co ML. An Easy Miss : Aortic Dissection in a Healthy Male. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 669. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/an-easy-miss-aortic-dissection-in-a-healthy-male/. Accessed September 22, 2019.