a rare cause of chest pain in a healthy teen rare cause of chest pain in a healthy teen monisha...
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A Rare Cause of Chest Pain in a Healthy Teen
Monisha Shah, MD1, Barra Alabd Alrazzak, MD2, Ann Marshburn, MD 1, Benjamin Mouser , MD1, Adil Solaiman, MD1
1Department of Pediatrics 2Department of Pediatric Gastroenterology and NutritionUniversity of Texas Health Science Center at Houston, Houston, TX
PRESENTED BY: Monisha Shah, MD, PGY3
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Disclosure of Financial Relationships
• No financial disclosures
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History of Present Illness• 17 y/o healthy M presented to OSH ER with 2 days of subjective fevers,
difficulty breathing and severe, sharp substernal chest pain
• Gradually worsening
• Constant
• Achy, non-pleuritic
• Radiating to mid chest
• Unchanged with position
• No history of trauma
• No aggravating/relieving factors
• Associated symptoms: diaphoresis, shortness of breath, sore throat, odynophagia, denies nausea/vomiting
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Other relevant past history
• Recent strep throat infection
• Other PMH/PSH/FH/SH non-contributory
• Denies smoking, alcohol use or recreational drug use
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Additional questions
• No family history of premature sudden cardiac death
• No prior episodes of chest pain
• No history of heart murmur
• No history of episodes of syncope
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Physical examination
•ER vital signs:
• T: 98.5°F (Oral)
• HR: 106 bpm
• RR: 18 breaths/min
• BP: 116/77
• SpO2: 97%
• HT: 185 cm (91%)
• WT: 73.5 kg (75%)
Physical Exam GEN: Alert, No acute distress
HEENT: PERRL. TMs clear. Posterior pharynx benign without lesions.
LUNGS: Clear bilaterally. No pleuritic pain.
HEART: Tachycardia. No murmurs. Capillary refill 2-3 seconds
CHEST WALL: No tenderness with palpation
MSK: Normal ROM, no swelling or deformities in any extremities
GI: Soft, NTND. No rebound or guarding. Negative Murphy’s sign.
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Initial Differential Diagnosis
What would you be worried about for this patient?
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Initial Differential Diagnosis• Life-threatening conditions:
• Cardiac : Classic and Variant angina, Myocarditis, Pericarditis, Arrhythmia, Aortic dissection, HOCM, DCM
• Pulmonary : Pneumothorax, Pulmonary hypertension, Pulmonary embolism
• Gastrointestinal: Esophageal rupture
• Common conditions:
• Musculoskeletal: costochondritis, muscle strain, or trauma
• Ingestion: caustic/corrosive agents, cocaine
• Psychogenic : panic attack, hyperventilation syndrome, or psychosomatic complaints
• Respiratory : asthma, pneumonia, or pleuritis
• Gastrointestinal disease: pill esophagitis, pancreatitis, GERD, or gastritis
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Initial ER workup • CBC w diff
• CMP
• UA
• UDS
• Rapid strep
• Cardiac enzymes (Total CK, CK-MB, troponin)
• Coagulation studies (PT, PTT, D-dimer, INR)
• EKG
• Chest X-ray
• CT angiogram
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Results
CXR:No chest radiographic evidence of acute cardiopulmonary disease.
CT angiogram:
FINDINGS: No pleural effusion or pericardial effusion. The heart is not enlarged. No evidence for pulmonary embolus. Lungs appear clear
IMPRESSION: Negative study.
140 104
293.6 1.02
1196
15
12.9
44.4
173
AST12ALT 21Alk Phos 73T Bili 1.4Lactic acid 1.1
Total CK 52 unit/L CK MB <0.5 ng/mL Troponin-I <0.02 ng/mL
PT 14.7 seconds INR 1.13PTT 33.8 seconds D-dimer: positive
UDS negative
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• Severe, progressive odynophagia
• Pain located in epigastric region
• Dehydrated due to decreased fluid intake
• Failed PO challenge at ER, transferred to our inpatient facility for higher level of care, pain control, and subspecialty consultation.
Inpatient Admission
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Inpatient Physical Exam• Admission vitals:
• T: 99.2 °F (Oral) HR: 79 (Peripheral) RR: 10 BP: 137/70
SpO2: 99%
• Admission exam:GEN: Alert, No acute distress
HEENT: PERRL. TMs clear. Posterior pharynx benign without lesions. Dry mucus membranes.
LUNGS: Clear bilaterally. No pleuritic pain.
HEART: Regular rate and rhythm, no murmurs. Capillary refill ~3 seconds
CHEST WALL: No tenderness with palpation
MSK: Normal ROM, no swelling or deformities in any extremities
GI: Soft, NTND. No rebound or guarding. Negative Murphy’s sign.
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Diagnostic Pause• How would order of DDx change with new information?
• Are there new items you would like to add to DDx?
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Hospital Course
• Failed PO challenge with exacerbation of pain on
oral intake
• Started on IV fluids, IV pantoprazole with sucralfate
and morphine for pain management
• Pediatric GI consulted
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• Lipase level obtained which was normal
• UGI series obtained which was normal
• In next 24 hours, worsening of pain, unable to swallow even secretions
• Emergent EGD obtained
Additional Inpatient Work-Up
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Middle esophagus
Esophagogastroduodenoscopy images showing severe pan-esophagitis.
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Pathology report
Duodenum – No significant histopathologic alterations.
Stomach – Mild chronic inflammation. Negative for H. pylori
Esophagus – Acute necrotizing pan-esophagitis. Positive for HSV on IHC stain
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Final hospital course
• Started on IV acyclovir
• HSV + immunohistochemical stain
• Immunodeficiency evaluation:
• HIV negative
• Normal growth parameters
• No history of serious bacterial infections
• New girlfriend with recent history of cold sores
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HSV Esophagitis• Extensively described in immunocompromised hosts
• Can be devastating and fatal in this population (1, 2).
• Only handful of case reports in healthy patients (1-10).
• A review looked at 38 healthy patients, both adult and pediatric with HSV esophagitis (1)
• 3:1 male predominance overall (increased to 90% in the pediatrics)• Typical patient was young, healthy, male (less than 18 years old in ¼ of
cases) presenting with :• acute odynophagia/dysphagia• chest pain• Heartburn • +/- Prodromal symptoms or oral lesions.
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What about chest pain?
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Remainder of clinical course• Rapid improvement in clinical status with resolution of chest
pain and dysphagia on initiation of acyclovir therapy
• Able to tolerate adequate PO intake on discharge
• Discharged to complete 7-day course of PO valacyclovir
• Scheduled to follow up in GI clinic in 2 weeks, but by that time, symptoms had resolved and family canceled the follow up visit.
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Take Home Points• Cardiac etiology least common cause of chest pain in pediatrics (4-6%)
(11)
• Patients with esophagitis frequently present with retrosternal “chest pain” (1, 7, 9).
• Diagnosis achieved by characteristic appearance on EGD, biopsy specimens, positive HSV IHC stain
• Esophagitis should be considered for all patients presenting with the triad of chest pain, odynophagia, and fever, as early recognition can prevent broad cardiopulmonary workups (10).
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References 1. Ramanathan J, Rammouni M, Baran J, Khatib R. Herpes simplex virus esophagitis in the immunocompetent host: an overview.
Am J Gastroenterol. 2000;95(9):2171-6.
2. Lee B, Caddy G. A rare cause of dysphagia: herpes simplex esophagitis. World J Gastroenterol. 2007;13(19):2756-7.
3. Canalejo castrillero E, García durán F, Cabello N, García martínez J. Herpes esophagitis in healthy adults and adolescents: report of 3 cases and review of the literature. Medicine (Baltimore). 2010;89(4):204-10.
4. De-la-riva S, Muñoz-navas M, Rodríguez-lago I, Carrascosa J, Idoate MÁ, Carias R. Herpetic esophagitis: a case report on an immunocompetent adolescent. Rev Esp Enferm Dig. 2012;104(4):214-7.
5. Galbraith JC, Shafran SD. Herpes simplex esophagitis in the immunocompetent patient: report of four cases and review. Clin Infect Dis. 1992;14(4):894-901.
6. Marinho AV, Bonfim VM, De alencar LR, Pinto SA, De araújo filho JA. Herpetic esophagitis in immunocompetent medical student.Case Rep Infect Dis. 2014;2014:930459.
7. Al-hussaini AA, Fagih MA. Herpes simplex ulcerative esophagitis in healthy children. Saudi J Gastroenterol. 2011;17(5):353-6.
8. Kurahara K, Aoyagi K, Nakamura S, et al. Treatment of herpes simplex esophagitis in an immunocompetent patient with intravenous acyclovir: a case report and review of the literature. Am J Gastroenterol. 1998;93(11):2239-40.
9. Rongkavilit C, El-baba MF, Poulik J, Asmar BI. Herpes simplex virus type 1 esophagitis in an immunocompetent adolescent. DigDis Sci. 2004;49(5):774-7.
10. Jibaly R, LaChance J, Abdulhammour W. Herpes simplex esophagitis: Report of 4 pediatric cases in immunocompetent patients. JPediatr Infect Dis 2011;6(3):205-9
11. Eslick GD. Epidemiology and risk factors of pediatric chest pain: a systematic review. Pediatr Clin North Am. 2010;57(6):1211-9.
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Questions?..