UNCOMMON CAUSES OF CHEST PAIN....

In the daily practice of emergency medicine, we all come across the common causes of chest pain, such as Angina, Acute MI, pericarditis, Pleurisy, PE and an occasional Thoracic Dissection.

But often, even after extensive work-up, the diagnosis remains elusive...thus, making the diagnosis of ATYPICAL CHEST PAIN or UNDETERMINED CHEST PAIN common.


The list below is partial, but including them in your differentials, will certainly help close the gap!


UNCOMMON CAUSES OF CHEST PAIN:


   1. DRESSLER'S SYNDROME
      
       CLUES: Recent myocardial infarction. Normal cardiac enzymes. Fever. Elevated ESR.
                      Benign of pericarditis like findings on EKG.

 
   2. ACUTE PNEUMOMEDIASTINUM

       CLUES: Main symptom is severe chest pain, due to rupture of alveolar blebs with air
                      escaping into the mediastinum. Can palpate subcutaneous crepitations,
                      especially at the suprasternal notch/anterior neck. No dyspnea as opposed to
                      an acute pneumothorax.


   3. BOERHAAVE'S SYNDROME

       CLUES: Repeated emesis with sudden onset of intense chest pain, causing the tear in
                      the esophageal wall. CXR will show pneumonia-like findings. An increases
                      serum amylase and WBC is also key.  Condition can be especially common
                      in post head/neck radiation patient, esophageal cancer patient or in  patients
                      with previous damage of esophagus due to corrosive ingestion.


  4. ACUTE VARICELLA ZOSTER

      CLUES: Generally elderly patient presenting to ED with sharp stabbing pain, without
                     an obvious cause, involving the specific dermatome.  Can be challenging to
                     diagnose, as pain always occurs 2-3 days before the rash.


  5. CORKSCREW/NUTRCRACKER ESOPHAGUS

      CLUES: Due to an esophageal motility disorder, causing severe intense episodic chest
                     pains, especially after consuming carbonated beverages. The esophagus is
                     spasmodic and hypercontracting. Difficult to diagnose, as patients repeatedly
                     present to ED's with chest pain. Diagnosis: Barium swallow and best confirmation
                     study is Manometric Study of Esophagus.


 6. ACUTE CHEST SYNDROME

     CLUES: This is a complication of Sickle Cell Anemia affecting a subset of patients.
                    Carries a high mortality, if not treated early. Pathophysiology involves occlusion
                    of pulmonary microvasculature by deformed (sickled) RBC.'s causing infarction.


 7. KAWASAKI DISEASE

     CLUES: It is a form of vasculitis involving small-medium coronary arteries, causing blood
                    vessel aneurysms, that lead rupture, causing myocardial infarction.
                   This is the most common acquired coronary vascular disorder in children
                   Death can be sudden an unpredictable.





Thanks for your time. Will continue soon.