SESSION TITLE: Critical Care Student/Resident Case Report Posters III
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Hemoptysis has been rarely reported as the sole presentation of aortic dissection in elderly, but not in young, healthy patients. Here we present such case.
CASE PRESENTATION: A 30 year-old Caucasian woman with history of recurrent sinus infection, remote pneumonia, 7PPY smoking, presented with 2 episodes of hemoptysis over a month. She denied fever, night sweat, weight loss, chronic cough, wheezing, chest pain, SOB or chest trauma. She was born in California, traveled extensively abroad for work, and spent 2 months in Sierra Leone. The first episode of a quarter cup was preceded by throat irritation and hoarseness, with admixture of mucous and blood. The second episode 2 weeks later was mostly blood. The patient underwent unremarkable direct laryngoscopy and chest x-ray. In anticipation of bronchoscopy, the patient underwent CT-chest which showed 5.4cm aneurismal dilatation of the aortic root with intimal dissection (Type A) involving the ascending aorta with extension just proximal to the takeoff of the left subclavian artery. Emergent aortic aneurysm repair revealed extensive cystic medial degeneration and focal hemorrhage.
DISCUSSION: Hemoptysis, as the sole presenting symptom of thoracic aortic dissection, is extremely uncommon, especially in young, otherwise healthy person. Over 90% of cases of thoracic aortic dissection present with severe, unremitting chest pain.1 Hemoptysis may occur if the aneurysm compresses the tracheobronchial tree or lungs, erodes into pulmonary vessels or a fistula forms between the aneurysm and tracheobronchial tree. Thoracic aortic aneurysms most often result from cystic medial degeneration, leading to weakening of the aortic wall which occurs usually with aging and hypertension. Aneurysms in young patients occur in inflammatory or infectious vasculitides such as Takayasu arteritis, Rheumatoid arthritis and Syphilitic aortitis or collagen disorders such as Marfan syndrome or Ehlers-Danlos syndrome. There is also a familial association of aortic aneurysms independent of such disorders. Our patient has neither family history nor clinical signs/symptoms suggestive of these disorders. Based on her pathological finding, she might benefit from testing FBN1 (Fibrillin-1) gene mutation to rule out Marfan syndrome as she meets the aortic criterion (aortic diameter >=2cm) according to ‘Revised Ghent nosology’ for diagnosis of Marfan syndrome.2
CONCLUSIONS: Hemoptysis is an extremely rare presenting symptom of aortic dissection. In the absence of pain in aortic dissection, the diagnosis is potentially overlooked and can lead to delayed treatment. This case highlights the need to include aortic dissection in differential diagnosis for hemoptysis.
Reference #1: Spittell PC, Spittell JA Jr, Joyce JW, Clinical features and differential diagnosis of aortic dissection:in 236 cases(1980 through 1990). Mayo Clin Proc1993;68:642
Reference #2: Loeys BL, Dietz HC, Braverman AC, The revised Ghent nosology for the Marfan syndrome.J Med Genet 2010;47:476
DISCLOSURE: The following authors have nothing to disclose: Min-Hui Chen, Ravindra Rajmane
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