-
Internal Medicine (Tokyo, Japan) 2022Objective Epipericardial fat necrosis (EFN) has been considered to be a rare cause of acute chest pain, and especially important for emergency physicians. Chest computed...
Objective Epipericardial fat necrosis (EFN) has been considered to be a rare cause of acute chest pain, and especially important for emergency physicians. Chest computed tomography (CT) is often used for the diagnosis of EFN after excluding life-threatening states, such as acute coronary syndrome and pulmonary embolism. While the proportion of EFN patients who underwent chest CT in emergency departments is being clarified, little is still known about other departments in Japan. To investigate the proportion of EFN patients who underwent chest CT for acute chest pain in various departments. Methods Chest CT performed from January 2015 to July 2020 in Asahikawa Medical University Hospital in Japan was retrospectively analyzed in this study. All images were reviewed by two radiologists. Results There were 373 outpatients identified by a search using the word 'chest pain' who underwent chest CT. Eight patients satisfying the imaging criteria were diagnosed with EFN. The proportions of patients diagnosed with EFN were 10.7%, 4.8%, 2.8%, 0.9% and 0% in the departments of general medicine, cardiovascular surgery, emergency medicine, cardiovascular internal medicine and respiratory medicine, respectively. Only 12.5% of the patients were correctly diagnosed with EFN, and the other patients were treated for musculoskeletal symptoms, acute pericarditis or hypochondriasis. Conclusion EFN is not rare and is often overlooked in various departments. All physicians as well as emergency physicians should consider the possibility of EFN as the cause of pleuritic chest pain.
Topics: Chest Pain; Diagnosis, Differential; Fat Necrosis; Humans; Japan; Pericardium; Retrospective Studies
PubMed: 35965074
DOI: 10.2169/internalmedicine.8161-21 -
BMJ Case Reports Dec 2023A female patient in her mid-60s presented with progressive shortness of breath, pleuritic chest pain and bilateral leg swelling for 1 week. Initial diagnostic workup...
A female patient in her mid-60s presented with progressive shortness of breath, pleuritic chest pain and bilateral leg swelling for 1 week. Initial diagnostic workup revealed pericardial effusion, and a localised pericardial tubular mass on CT chest. Pericardial fluid analysis showed elevated white cells, with predominance of medium-large sized atypical lymphoid cells. Atypical lymphocytes stained positive for CD79a, CD10, PAX-5, BCL-2 and BCL6. Fluorescence in situ hybridisation testing demonstrated MYC and BCL6 rearrangements without BCL2 gene rearrangement. The overall morphological, immunohistochemical and cytogenetic findings supported a diagnosis of high-grade B cell lymphoma with MYC and BCL6 rearrangements. After extensive staging workup, localised disease involving the pericardium with a diagnosis of primary cardiac large B cell lymphoma was established. She was treated with dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin and rituximab chemotherapy. Rituximab was discontinued owing to largely absent CD20 expression. Interim positron emission tomography-CT after three cycles revealed a complete response, and the patient completed six cycles of therapy.
Topics: Humans; Female; Rituximab; Proto-Oncogene Proteins c-myc; Proto-Oncogene Proteins c-bcl-6; Lymphoma, Large B-Cell, Diffuse; Cyclophosphamide; Vincristine; Prednisone; Doxorubicin; Antineoplastic Combined Chemotherapy Protocols
PubMed: 38151268
DOI: 10.1136/bcr-2023-256167 -
European Journal of Case Reports in... 2020Stab-like localized chest pain, aggravated by breathing, is compatible with pleuritic pain or with aching related to chest wall abnormalities. Local tenderness inflicted...
UNLABELLED
Stab-like localized chest pain, aggravated by breathing, is compatible with pleuritic pain or with aching related to chest wall abnormalities. Local tenderness inflicted by palpation helps to differentiate pleuritic from musculoskeletal chest pain and serves as a principal accessory manoeuvre in the algorithm of chest pain evaluation. Herein, we report the case of a 27-year-old patient with pulmonary thromboembolism and right lower lobe consolidation/atelectasis. The patient presented with right-sided chest pain, radiating to the shoulder, related to pleural irritation, yet associated with confounding intense chest wall tenderness and guarding, also involving the costovertebral angle. We propose that spinal reflex-related chest wall tenderness was involved, similar to peritoneal signs evoked by irritation of the parietal peritoneum. This case report illustrates that localized chest wall tenderness and guarding, triggered by palpation, may not serve as unequivocal indicators of musculoskeletal pain, and could be unrecognized features of pleuritic chest pain also.
LEARNING POINTS
Pleuritic chest pain may be associated with local tenderness and guarding.These unrecognized features of pleurisy supposedly reflect a spinal reflex, initiated by nociceptors in the parietal pleura.Local pain inflicted upon palpation and guarding may not serve as unequivocal indicators of musculoskeletal chest pain.
PubMed: 33083347
DOI: 10.12890/2020_001657 -
Psychiatry Research Nov 2021Clozapine is a second-generation antipsychotic often used for treatment-refractory schizophrenia and has many adverse effects. Cardiac adverse events potentiated by...
Clozapine is a second-generation antipsychotic often used for treatment-refractory schizophrenia and has many adverse effects. Cardiac adverse events potentiated by clozapine include myocarditis which is a black box warning. Even more rarely, there are multiple cases of pericarditis reported in the literature. This is a case report of a 32-year old male with paranoid schizophrenia who developed pericarditis after initiation and titration of clozapine in the inpatient psychiatry unit. Patient presented with chest pain, persistent tachycardia, and orthostatic hypotension two weeks after titration of clozapine. The diagnosis of pericarditis was supported by the repeat electrocardiogram which revealed PR depressions, the audible friction rub, and the pleuritic/episodic nature of the chest pain. All other possible causes of pericarditis were ruled out and clozapine was suspected as the most likely explanation. The pericarditis resolved with treatment of colchine and ibuprofen on evidence from a repeat echocardiogram. This case report demonstrates and supports few cases of clozapine induced pericarditis in the literature. Cardiac events of clozapine can be life-threatening; therefore, greater baseline and subsequent cardiac monitoring may be implicated in the future.
Topics: Adult; Antipsychotic Agents; Clozapine; Humans; Male; Myocarditis; Pericarditis; Schizophrenia, Paranoid
PubMed: 34749222
DOI: 10.1016/j.psychres.2021.114250 -
Cureus Aug 2022Chemotherapy-associated pneumothorax is a rarely encountered oncological emergency. Herein, we present a rare chemotherapy-associated bilateral secondary spontaneous...
Chemotherapy-associated pneumothorax is a rarely encountered oncological emergency. Herein, we present a rare chemotherapy-associated bilateral secondary spontaneous pneumothorax case of a man in his 60s with invasive breast carcinoma after four cycles of chemotherapy. He presented to our emergency department with acute onset dyspnea and left-sided pleuritic chest pain. A chest X-ray showed a left-sided pneumothorax, and an intercostal chest tube (ICT) was inserted with underwater seal drainage. After three days, he complained of sudden onset right-sided chest pain and increased dyspnea. A repeat chest X-ray revealed right-sided pneumothorax, which was managed with ICT again. Bilateral pleurodesis was done after a repeat chest x-ray showed complete lung re-expansion. The patient was doing well with no recurrence of pneumothorax after three months of follow-up. Male breast cancer is uncommon, and presentation with bilateral secondary spontaneous pneumothorax is rare. This case is reported as a rare complication of chemotherapy-associated bilateral spontaneous pneumothorax.
PubMed: 36176881
DOI: 10.7759/cureus.28478 -
The American Journal of Dermatopathology Sep 2020
PubMed: 32833741
DOI: 10.1097/DAD.0000000000001524 -
Radiology Case Reports Aug 2024Epipericardial fat necrosis is a rare cause of acute pleuritic chest pain and is a benign and self-limiting condition. It is important to distinguish epipericardial fat...
Epipericardial fat necrosis is a rare cause of acute pleuritic chest pain and is a benign and self-limiting condition. It is important to distinguish epipericardial fat necrosis from other diseases that cause acute chest pain, such as acute myocardial infarction, pulmonary embolism, and acute pericarditis, because conservative treatment is recommended for epipericardial fat necrosis. This report presents the case of a 25-year-old man with severe pleuritic chest pain located on the left anterior side that was associated with dyspnea. Electrocardiogram and laboratory data were normal, except for a slight elevation of C-reactive protein level. Contrast-enhanced chest computed tomography revealed a fatty ovoid lesion surrounded by a thick rim on the left side of the pericardial fat. Fat stranding was observed both inside and adjacent to the fatty ovoid lesion. A slight contrast enhancement of the thick rim and a slight linear enhancement inside the lesion were observed. Furthermore, a small amount of left pleural effusion was observed. The patient was diagnosed with epipericardial fat necrosis and treated with analgesics, and the symptoms improved 1 week after the emergency department visit. Radiologists should be familiar with epipericardial fat necrosis to prevent overlooking and misdiagnosing the condition.
PubMed: 38737185
DOI: 10.1016/j.radcr.2024.04.022 -
Chest Jul 2022A 50-year-old woman with a history of permanent atrial fibrillation (AF) treated with radiofrequency catheter ablation (RFCA) 6 months ago was admitted to the...
A 50-year-old woman with a history of permanent atrial fibrillation (AF) treated with radiofrequency catheter ablation (RFCA) 6 months ago was admitted to the respiratory department of a tertiary hospital because of recurrent episodes of pleuritic chest pain in the preceding 5 months. The patient reported multiple visits to a regional hospital, where she was treated with broad-spectrum antibiotics after discovery of a left alveolar consolidation on chest radiograph (Fig 1), subsequently imaged with CT scan (Fig 2). On treatment failure and appearance of a left-sided pleural effusion during outpatient follow-up, the patient was re-admitted. Pleural fluid was obtained via thoracocentesis characterized by exudative features and lymphocytic predominance. Abdomen CT scan, with IV and per os contrast agent, was devoid of findings consistent with malignancy, and serum autoantibody levels were below positivity cut off values (antinuclear, cyclic citrullinated peptide antibody, rheumatoid factor, and anti-neutrophil cytoplasmic antibodies). The patient underwent flexible bronchoscopy without endobronchial pathology on visual inspection. Microbiologic studies and cytological examination of samples obtained by bronchial washing/aspiration yielded no clinically relevant information. Lung perfusion/ventilation scintigraphy was ordered to exclude chronic thromboembolic pulmonary hypertension; however, a deficit in vascularization for the left inferior lobe was found, prompting further investigation (Fig 3). Progression of left inferior lobe consolidation and the presence of a small pericardial effusion became evident on reimaging after a 2-month interval. The patient was empirically started on corticosteroids. After emergence of left hilar lymphadenopathy (< 1 cm), a PET-CT scan was performed. The left lower inferior lobe consolidation, whose metabolic activity pattern was consistent with that of inflammation (standardized uptake value equal to 4.4) (Fig 4), as well as the left sided-pleural effusion were markedly improved compared with previous imaging 20 days after corticosteroid initiation (Fig 2). On the grounds of recalcitrant pleuritic pain and pleural effusion recurrence during corticosteroid tapering, the patient was referred to the respiratory department of our university hospital to have her condition diagnosed.
Topics: Adrenal Cortex Hormones; Chest Pain; Female; Humans; Middle Aged; Pleural Effusion; Positron Emission Tomography Computed Tomography; Thoracentesis
PubMed: 35809948
DOI: 10.1016/j.chest.2022.02.034 -
Journal of Global Infectious Diseases 2022has been rarely mentioned as a causative organism of thoracic empyema in previous literature. Here, we reported two cases (a 66-year-old male farmer and a 57-year-old...
has been rarely mentioned as a causative organism of thoracic empyema in previous literature. Here, we reported two cases (a 66-year-old male farmer and a 57-year-old male security guard) presenting with fever and pleuritic chest pain. Their chest computed tomography scans revealed pleural effusion which was frank pus confirmed through thoracentesis. The result of pus culture isolated suitable to diagnose melioidosis. These patients were treated successfully with appropriate antibiotics without chest tube drainage. Although uncommon, melioidosis could present exclusively as thoracic empyema.
PubMed: 35910825
DOI: 10.4103/jgid.jgid_211_21 -
Journal of Opioid Management 2022We sought to understand opioid prescribing for COVID-19 positive and negative patients with pleuritic pain during the first wave of the pandemic. We hypothesized that...
OBJECTIVE
We sought to understand opioid prescribing for COVID-19 positive and negative patients with pleuritic pain during the first wave of the pandemic. We hypothesized that patients without COVID-19 would be prescribed opioids more frequently intrapandemic compared to prepandemic and postulated that COVID-19 patients would be prescribed opioids more frequently and at greater quantity than their peers.
DESIGN
A retrospective observational analysis of electronic health record data.
SETTING
A quaternary academic hospital from February through April 2020.
PARTICIPANTS
A total of 1,400 of 3,169 adult inpatient hospitalizations involving pleuritic pain were included.
MAIN MEASURES
Frequency and average daily dose of opioid prescriptions were analyzed using logistic and linear regression. Opioid prescribing habits were compared pre- and intrapandemic. Hypotheses and primary outcome measures were formulated prior to data collection.
KEY RESULTS
During the pandemic, COVID-19 patients were 15.77 absolute percentage points less likely to be prescribed opioids compared to patients without COVID-19 (95 percent confidence interval (CI): -8.98 to -22.56 percent). Patients without COVID-19 were equally likely to be prescribed opioids pre- and intrapandemic (95 percent CI: -9.37 to 2.42 percent). Odds ratio of opioid prescription for COVID-19 patients was 0.44 (95 percent CI: 0.08-0.80). Within those given opioids, COVID-19 patients were prescribed 3.0 percent greater morphine milligram equivalents (MMEs) (95 percent CI: 1.07-5.85 percent).
CONCLUSION
During the first wave of the pandemic, COVID-19 patients with pleuritic pain were prescribed opioids less frequently than patients without COVID-19, while patients without COVID-19 were equally likely to be prescribed opioid pre- and intrapandemic. On the other hand, COVID-19 patients treated with opioids were given greater daily MMEs due to the greater utilization of opioid infusions.
Topics: Adult; Humans; Analgesics, Opioid; Pandemics; Retrospective Studies; Practice Patterns, Physicians'; COVID-19; Pain; Pain, Postoperative; Drug Prescriptions
PubMed: 36523204
DOI: 10.5055/jom.2022.0748