A 29-Year-Old Man with Dyspnea and Chest Pain [Pulmonary Embolism and an Intracardiac Mass Due to A Metastatic Germ-Cell Tumor]
A 29-year-old man was admitted to this hospital because of severe dyspnea and chest pain on the right side.
The patient, who was a highly trained athlete, had been well until approximately 2.5 weeks before admission, when he was hit in the chest while he was at work; headache and nausea occurred for 3 days thereafter.
Approximately 2 weeks before admission, he awoke at night with pain in the right midaxillary region that he described as a “ping-pong ball”; the pain radiated to and from the right scapula and was associated with shortness of breath. He arose, and after pacing and calming himself, he was able to sleep again.
The next day, he went to an urgent care clinic in another city, where a diagnosis of muscle spasm was made. Muscle relaxants and ibuprofen were administered, without improvement.
During the following days, increasing dyspnea occurred with minimal exertion; the pain became localized to the right anterior chest and had a sharp, stabbing quality, and a nonproductive cough developed.
Three days before admission, during a 1.5-hour flight to Massachusetts, the patient noted having leg cramps, which was a usual occurrence for him on flights.
On the morning of admission, he felt well on awakening, but sudden stabbing chest pain in the sternal area later developed, with associated severe pressure in his chest and transient palpitations. While the patient was walking, he noted severe shortness of breath, with increasing tachypnea and difficulty talking. Chest pain increased with coughing, laughing, and sneezing.
In the evening, the patient went to another hospital for evaluation, where he reported sharp chest pain on the right side that worsened with deep breaths; he rated the pain at 8 on a scale of 0 to 10, with 10 indicating the most severe pain. He attributed some of his symptoms to his earlier chest injury.
On examination, the patient reportedly appeared to be well. The blood pressure was 138/82 mm Hg, the pulse 89 beats per minute, the temperature 36.8°C, the respiratory rate 18 breaths per minute, and the oxygen saturation 98% while he was breathing ambient air. The remainder of the examination was normal.
The hematocrit, hemoglobin level, red-cell indexes, and blood levels of electrolytes, glucose, calcium, total protein, albumin, total bilirubin, alanine aminotransferase, and alkaline phosphatase were normal. An electrocardiogram (ECG) revealed normal sinus rhythm with a rightward axis. Naproxen and cyclobenzaprine hydrochloride were administered, with some improvement.
Rosenfield K, Ghoshhajra BB, Dudzinski DM, Stone JR. Case 9-2016 — A 29-Year-Old Man with Dyspnea and Chest Pain. New England Journal of Medicine 2016;374(12):1178-88. MMS: Error
Imaging Studies of the Chest.
A posteroanterior chest radiograph (Panel A) shows a masslike opacity in the midlung zone behind the right hilum (arrow) and enlarged pulmonary arteries.
Axial contrast-enhanced CT angiographic images were obtained at the lung-window setting (Panel B) and at the mediastinal-window setting (Panels C and D) at the level of the midchest.
A mottled, wedge-shaped air-space opacity is present in the periphery of the right lower lobe (Panel B).
A smooth, large, central filling defect (Panels B and C, arrows) is present that extends from the main pulmonary artery (MPA) to the right pulmonary artery (RPA).
Central filling defects are also present in the interlobar and lobar branches of the right pulmonary artery (Panel D, arrows); the right ventricular outflow tract (RVOT) contains an irregular central filling defect with central contrast-filling channels rather than enhancement.
An axial CT angiographic image (Panel E) shows a dilated right ventricle (RV), with a ratio of RV diameter to left ventricular (LV) diameter of 1.6 (normal, <1); a heterogeneously enhancing filling defect is evident in the RV cavity (arrow), as well as in the right atrium (not shown).
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