Case Presentation:
A 54‐year‐old man with a history of hypertension and gastroesophageal reflux presented to the emergency department with a sore throat. He had sprinted up a flight of stairs and soon developed a severe, sharp, throbbing pain in the base of his throat, associated with shortness of breath and radiation of the pain to his upper chest and back. Concerned that he was having a heart attack, he took a nitroglycerin tablet and aspirin prior to admission. Further questioning revealed a six month history of experiencing bouts of throat and chest pain with exertion and relieved with rest. Otherwise, he denied upper respiratory infection symptoms, and exam showed normal neck, oropharynx, and cardiac findings. Initial troponin level was normal and chest x‐ray in the ED showed a normal mediastinum with stable cardiomegaly. Despite the unremarkable chest x‐ray findings and unusual presenting symptoms, a chest CT angiogram was ordered on the basis of history and showed Stanford type A aortic dissection extending from the sinotubular junction to the level of the diaphragmatic hiatus involving all three great vessels with extension into all distal portions of the bilateral common carotid arteries, with concomitant aneurysmal dilatation of the ascending aorta and proximal arch. He was airlifted to the main hospital campus for emergent surgical repair with a tube graft.
Discussion:
The inciting event in aortic dissection is a tear of the intima allowing bleeding into the aortic wall, forming an intramural hematoma. Hypertension is the leading contributing factor, with atherosclerosis being secondary. Incidence of aortic dissection has been quoted as 2.9 per 100,000 per year, and mortality of acute dissection has been reported as high as 40‐50% within 48 hours if not surgically treated. Fatality rates have improved as advanced surgical techniques have been introduced, with a 30 day survival rate of 80‐85% when surgery is performed at experienced tertiary care centers. In contrast, sore throat is a commonly occurring condition prompting urgent care and emergency room visits, but a benign infectious etiology is usually evident when pharyngitis or cervical lymphadenopathy is noted on exam.
Conclusions:
Only one case of aortic dissection presenting with a chief complaint of sore throat has been previously reported, and a delayed diagnosis resulted in the patient’s death. Our patient’s neck discomfort prompted his admission to evaluate for angina, a more common presenting condition, but ultimately was the incorrect conclusion. The diagnosis of acute aortic dissection type A is complicated owing to the vast differential diagnosis for chest pain, the relatively low incidence of the disease, and the varied potential presenting symptoms of acute dissection. Clinically, patients may report acute pain, syncope due to rupture or pericardial tamponade, or have signs of organ hypoperfusion including acute stroke, MI, or spinal cord syndromes. Hospitalists are in a unique position to promptly diagnose aortic dissection via attentive history and exam, and facilitate expedient care for this vascular emergency, correlating to improved long‐term survival. Entertaining suspicion for dissection in patients presenting without classically described symptoms provides an opportunity for hospitalists to impact mortality in one of the most common and serious aortic diseases and to champion the judicious use of radiologic testing modalities.