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Noncardiac chest pain in a patient with cardiac pathology: the importance of an accurate history.

Wood A, Hew R, McCann G - JRSM Open (2014)

View Article: PubMed Central - PubMed

Affiliation: Glenfield Hospital, Leicester LE3 9PQ, UK.

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This report demonstrates the importance of making a diagnosis in patients with chest pain, rather than simply excluding myocardial infarction... A 70-year-old man with hypertension but no other medical history was admitted with chest pain, described as ‘sharp’ with no radiations, and 10/10 in severity... There was no associated nausea or sweating; the pain came on at rest, although he had been doing an unusual amount of heavy lifting prior to the admission... The initial working diagnoses were of an acute coronary syndrome or musculoskeletal chest pain, on a background of left ventricular hypertrophy (LVH)... Bedside echocardiography showed significant apical hypertrophy (2.7 cm wall thickness) with no other abnormalities and no features of aortic dissection... It has however become common (though not ideal) in routine practice to assess patients, exclude myocardial ischaemia and then discharge them with a label of ‘noncardiac chest pain’, which has almost become a diagnosis in itself... This case illustrates the importance of looking for a specific diagnosis, rather than simply excluding the most immediately life-threatening possibilities and then reassuring the patient... Extraosseous plasmacytoma rarely progresses, whereas osseous plasmacytoma is thought to represent early myeloma and generally progresses to the systemic disease... Myeloma can be associated with LVH because of amyloid deposition within the heart; however, this was clearly not the cause of the LVH in this gentleman – his ECG would be very atypical for cardiac amyloid, and his MRI scan demonstrated regional (apical) hypertrophy with normal gadolinium kinetics and ing... Cardiac amyloid would be expected to show global subendocardial late gadolinium enhancement and high myocardial gadolinium concentrations early after injection... On this occasion the extra cardiac diagnosis was essentially made by luck – if the diagnosis of HCM had been made conclusively on echocardiography, he would have been discharged home without the plasmacytoma being identified... However, it illustrates the importance of taking a detailed history and not being misled by the circumstances in which the patient presents, or by the apparently obvious cardiac diagnosis... In retrospect, this patient’s pain was not anginal in character, and is likely to have been due to the plasmacytoma encroaching on an intercostal nerve, but as the patient presented to a coronary care unit with an abnormal ECG, it was felt necessary to exclude an acute coronary syndrome.

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Plasma cell infiltration including atypical forms. Haematoxylin and eosin section, ×40 magnification.
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fig6-2042533313518916: Plasma cell infiltration including atypical forms. Haematoxylin and eosin section, ×40 magnification.

Mentions: The CMR scan did indeed confirm apical HCM (Figures 2–4, chamber view); however, it also showed a lesion in the chest wall (Figure 3). Subsequent computed tomography revealed an osteolytic lesion in the left posterior sixth rib encroaching on the intercostal nerve (Figure 4). A biopsy of this lesion revealed a plasma cell neoplasm (Figures 5, 6 and 7).Figure 2.


Noncardiac chest pain in a patient with cardiac pathology: the importance of an accurate history.

Wood A, Hew R, McCann G - JRSM Open (2014)

Plasma cell infiltration including atypical forms. Haematoxylin and eosin section, ×40 magnification.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License 1 - License 2 - License 3
Show All Figures
getmorefigures.php?uid=PMC4012672&req=5

fig6-2042533313518916: Plasma cell infiltration including atypical forms. Haematoxylin and eosin section, ×40 magnification.
Mentions: The CMR scan did indeed confirm apical HCM (Figures 2–4, chamber view); however, it also showed a lesion in the chest wall (Figure 3). Subsequent computed tomography revealed an osteolytic lesion in the left posterior sixth rib encroaching on the intercostal nerve (Figure 4). A biopsy of this lesion revealed a plasma cell neoplasm (Figures 5, 6 and 7).Figure 2.

View Article: PubMed Central - PubMed

Affiliation: Glenfield Hospital, Leicester LE3 9PQ, UK.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

This report demonstrates the importance of making a diagnosis in patients with chest pain, rather than simply excluding myocardial infarction... A 70-year-old man with hypertension but no other medical history was admitted with chest pain, described as ‘sharp’ with no radiations, and 10/10 in severity... There was no associated nausea or sweating; the pain came on at rest, although he had been doing an unusual amount of heavy lifting prior to the admission... The initial working diagnoses were of an acute coronary syndrome or musculoskeletal chest pain, on a background of left ventricular hypertrophy (LVH)... Bedside echocardiography showed significant apical hypertrophy (2.7 cm wall thickness) with no other abnormalities and no features of aortic dissection... It has however become common (though not ideal) in routine practice to assess patients, exclude myocardial ischaemia and then discharge them with a label of ‘noncardiac chest pain’, which has almost become a diagnosis in itself... This case illustrates the importance of looking for a specific diagnosis, rather than simply excluding the most immediately life-threatening possibilities and then reassuring the patient... Extraosseous plasmacytoma rarely progresses, whereas osseous plasmacytoma is thought to represent early myeloma and generally progresses to the systemic disease... Myeloma can be associated with LVH because of amyloid deposition within the heart; however, this was clearly not the cause of the LVH in this gentleman – his ECG would be very atypical for cardiac amyloid, and his MRI scan demonstrated regional (apical) hypertrophy with normal gadolinium kinetics and ing... Cardiac amyloid would be expected to show global subendocardial late gadolinium enhancement and high myocardial gadolinium concentrations early after injection... On this occasion the extra cardiac diagnosis was essentially made by luck – if the diagnosis of HCM had been made conclusively on echocardiography, he would have been discharged home without the plasmacytoma being identified... However, it illustrates the importance of taking a detailed history and not being misled by the circumstances in which the patient presents, or by the apparently obvious cardiac diagnosis... In retrospect, this patient’s pain was not anginal in character, and is likely to have been due to the plasmacytoma encroaching on an intercostal nerve, but as the patient presented to a coronary care unit with an abnormal ECG, it was felt necessary to exclude an acute coronary syndrome.

No MeSH data available.


Related in: MedlinePlus