Article, Cardiology

Rupture of aortic aneurysm with late right hemorrhagic pleural effusion

Case Report

Rupture of aortic aneurysm with late right hemorrhagic pleural effusion

Abstract

Aortic dissection is a critical condition requiring immediate assessment and management. Clinical presenta- tion is commonly associated with severe chest pain and high blood pressure. However, misdiagnosis is frequent because of various features. We present a case of 63-year-old man who complained of transient chest pain with spontaneous relieved when he arrived to our hospital. Hemodynamic instability detected 1 hour later without accompanying symptom, and his blood pressure was spontaneously improved on admission. The patient remained symptom free, and dull right chest pain developed on the fifth day of admission. Follow-up chest radiography revealed right pleural effusion. Thoracentesis showed hemorrhagic pleural effusion, and chest computed tomography demonstrated the rupture of aortic aneurysm into the right Pleural cavity and pericardial space. The case presented with unusual char- acteristics making a correct diagnosis initially less obvious.

A 63-year-old man was admitted to our emergency department (ED) complaining of sudden onset of chest pain when he was playing computer games. The pain radiated to back and associated with cold sweating and nausea for minutes, and it was spontaneously relieved when the patient arrived to our ED. He had neither systemic disease as hypertension nor medical history. His Blood pressure was 134/74 mm Hg, and pulse rate was 60 beats/min on arrival. Physical examination did not reveal any abnormal- ities. Chest radiography showed a grossly tortuous and unfolded thoracic aorta (Fig. 1, left). And his electrocardio- gram (ECG) revealed flatten T wave in precordial leads (V4- V6), but was otherwise unremarkable. Biochemical analysis demonstrated normal cardiac enzyme (troponin I, total creatine kinase, and CK-myocardial isoenzyme) level. One hour later, a drop of BP was noted (98/62 mm Hg) by regular follow-up at ED, but the patient was symptom free. There was no significant ECG change by continue monitoring. He was suggested to be admitted to our intensive care unit under the suspicion of acute coronary syndrome. The BP was

normal (137/66 mm Hg) on admission. During our intensive care unit, his vital sign was stable and the patient remained symptom free. There were neither further ECG changes nor cardiac enzyme abnormality by regular follow-up. On the fourth day of admission, the patient was transferred to ordinary ward. Echocardiography was performed, and the results showed good left ventricle contractility. Neither pericardial effusion nor significant valvular regurgitation was found. On the fifth day, the patient complained of slight right-sided chest pain. The pain is dull and persisted, with neither cold sweating nor radiation. The patient remained hemodynamic stable without respiration distress. His ECG did not show further changes, and repeated chest x-ray demonstrated a moderate amount right pleural effusion and slightly abnormal convex opacity of right hilum and right upper mediastinum (Fig. 1, right). A right thoracentesis was performed immediately, and it revealed thin, grossly hemorrhagic, reddish pleural fluid. There were neither organisms found by Gram stain nor malignant cells identified by cytology. A chest computer tomography was arranged, and it revealed dilated aortic arch (diameter, 4.0 cm) with large intimal flap. There were obvious hematomas on right hilum and right upper mediastinum in association with right pleural and pericardial effusions (Fig. 2). Then the patient was referred for surgical treatment.

Acute aortic dissection is a potential fatal condition requiring immediate assessment and therapy. The manage- ment demands either Surgical repair the dissected aorta or medial reduce arterial shear forces on the torn aortic site. Early diagnosis with minimal loss of time is the principle for prompt management. Without prompt management, the lethal nature of this catastrophic event is obvious in type A aortic dissection. Mortality rate increases 1% to -1.5% per hour for the first 24 hours, and there are more than 50% of patients dying in the first 48 hours, most from rupture into the pericardial, mediastinal, or pleural space [1,2]. However, misdiagnosis still remains an unresolved problem because of myriad and unpredictable clinical presentation together with certain limitations in imaging studies. widened mediastinum in a chest x-ray is a common finding, and it is presented in 60% to 90% of suspicious cases [3]. Although there is estimated up to 20% negative finding of chest x-ray in the International Registry of Acute Aortic Dissection study [4]. Arterial hypertension is the single most important factor

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1058.e2 Case Report

Fig. 1 Chest radiography on admission (left panel) and on the fifth day (right panel) shows moderate amount right pleural effusion and slightly abnormal convex opacity of the level of right hilum and right upper mediastinum.

Fig. 2 Chest computer tomography demonstrates dilated aortic arch (diameter, 4.0 cm) and a large intimal flap with inlet at aortic transverse arch and outlet at descending aorta. Asterisk (?) indicates hematoma on upper right mediastinal space. Left side pleural and pericardial effusions are illustrated; black arrowhead, false lumen; and white arrowhead, true lumen.

Case Report 1058.e3

among the causes of aortic dissection, and it is found in 80% of the patients [4]. Despite recent improvements in treatment, studies on dissecting aortic aneurysm have been limited in number. In addition to misdiagnosis, this is because many of the patients with nondiagnosed aortic dissection may have died before hospital [4,5]. As the result, its prevalence rate and natural history are still poorly understood. acute onset of chest pain is the most common initial complain. The initial symptoms can be easily confused with those of acute coronary syndrome. The confusion of dissecting aortic aneurysm with acute coronary syndrome not only delays correct diagnosis but also deteriorates prognosis due to treat with anticoagulant agents. Typical presentation of dissecting aortic aneurysm is severe and abrupt chest pain with described as tearing or stabling type. As acute coronary syndrome, the pain may radiate to back or abdomen, which depends on the dissection involved site. Anterior chest pain indicates Ascending aortic dissection, whereas patients with pain in the backs, lower backs, and abdomen suggests descending aortic dissection. In our case, initial anterior chest pain with radiation and cold sweating indicated the possibility, but spontaneous relief of the symptoms confused the Initial diagnosis. The other clinical presentation helpful in diagnosis was unstable BP. Hemodynamic instability, shock, and syncope could be the less common manifestations in acute aortic dissection. However, spontaneous improvement and stable hemodynamic with continue follow-up blunted the correct diagnosis in our case. Unlikely acute coronary syndrome, the chest pain of dissecting aortic aneurysm could migrate. In ordinary cases, it presents with moving downward as the torn aorta progress. The migrating chest pain in our case is unusual. Dull right-sided chest pain developed on the fifth day after admission. The clinical symptom hinted the hematoma accumulation in right upper mediastinal space from a vulnerable false lumen, and it was evidenced by chest x-ray follow-up. This also implied that aortic dissection was in progress. The correct diagnosis was further indicated by thoracentesis with hemorrhagic right pleural effusion. Hemorrhagic pleural effusion may present in various conditions. The different diagnosis includes traumatic injury, pulmonary infarction, pulmonary tubercu- losis, and pleuropulmonary malignancy. All the conditions share the priority in the differential diagnosis, but it could be a presentation sign of Ruptured aortic aneurysm. In previous study, most of hemorrhagic Pleural effusions in ruptured aortic aneurysm developed on the day of onset. In addition, most of the cases presented with either bilateral pleural effusions or left side effusion [6]. Right hemorrhagic pleural effusion associated with aortic dissection is extremely rare,

and there were scattered case reports [7,8]. In our case, transient chest pain with spontaneous relieved, and with neither arterial hypertension nor chest radiograph signifi- cance was a challenge in initial diagnosis. The possibility should be kept in mind when the patient accompanying with following hemodynamic instability despite spontaneous improvement. For the case, fortunately, the correct diagnosis was made on the fifth day when he complained of dull right-sided chest pain.

This case represented an Unusual presentation and revealed clinical evolution of aortic dissection. When clinical picture manifests with chest pain in association with hemodynamic instability, even the symptoms are spontaneous relieved, the possibility should be kept in mind. In particular, when migrating chest pain develops, extension of the dissected aorta may be indicated. Immediate evaluation and further image studies are emphasized to avoid catastrophe.

Hung Yi Chen MD

Department of Cardiology Taipei City Hospital-Heping Branch

Taipei City 100, Taiwan E-mail addresses: [email protected]

[email protected]

doi:10.1016/j.ajem.2010.01.019

References

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  4. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman JF, et al. The International Registry of Acute Aortic Dissection (IRAD)-new insights into an old disease. JAMA 2000;283:897-903.
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