Case Presentation:
Our patient is a 62-year-old Eastern European female with no significant past medical history who was brought to the emergency department after a sustaining a syncopal episode. At the time of exam, she was largely asymptomatic, and her review of systems was positive for a brief isolated episode of mild chest pain that resolved spontaneously five days prior to presentation. On examination, she was afebrile, normotensive, and non-toxic appearing, however, discrepancies in blood pressure readings and radial pulses between opposing arms were the only findings that prompted further workup.
A computed tomography (CT) scan revealed an extensive aortic dissection originating from the aortic root and extending into the common iliac arteries. Her dissection involved the brachiocephalic trunk, right common carotid, and was complicated by a hemorrhagic pericardial effusion. The patient was emergently taken for surgery during which she underwent complete repair of the ascending aortic dissection with aortic root replacement and reimplantation of the coronary arteries. The patient was managed in the intensive care unit following the operation.
Biopsy and surveillance culture of the resected aortic valve unexpectedly exhibited growth of Escherichia coli several days later, and additional antibiotic therapy was initiated. Based on this finding, we infer that this patient had subclinical aortic valve endocarditis and resultant aortitis which led to dissection. Unfortunately, despite aggressive supportive measures, the patient’s post-operative course was complicated by sepsis and multiorgan failure and ultimately resulted in the patient’s demise.
Discussion:
Dissection of the ascending aorta is a relatively rare condition and occurs at an estimated annual incidence of 3-4 cases per 100,000 persons. Known risk factors include hypertension, atherosclerosis, smoking, aortic aneurysm, aortic stenosis, cocaine use, bicuspid aortic valve, and connective tissue disorders such as Marfan Syndrome. Although much less common, infectious causes such as aortitis and syphilis are also established etiologies. Infectious aortitis is associated with high rates of rupture, and early diagnosis is important in preventing such outcomes. Furthermore, syncope, tamponade, pulse deficits, and delay in diagnosis are all high-risk features in ascending aortic dissection and are associated with high perioperative mortality.
Conclusions:
It is crucial to check pulses and blood pressure in opposing extremities in patients presenting with chest pain or syncope, as these were the only initial findings that led to the correct diagnosis. Unfortunately, the lack of clinical and laboratory evidence of infection led to a delay in the diagnosis and the initiation of antibiotic therapy. We urge clinicians to be wary of this life-threatening condition in patients that present with none of the classical risk factors, as early recognition and intervention are critical in lowering mortality.