Authors: Amelia Klamen B.S., Wouter Ritsema B.S., Ankit Hanmandlu M.D., Ayman Salem M.D., Sahalia Rashid M.D.

Introduction: Acute aortic dissection (AAD) is a highly lethal phenomena with a mortality rate of 50% within 48 hours. Timely diagnosis and management of AAD is crucial, yet often is delayed by ambiguous symptomatology. Patients commonly present with extreme chest pain, dyspnea, and abdominal pain, but clinical presentation can also include focal neurological defects, altered mentation, and syncope.

Case Description: A 56 year old man with a history of hypertension, asthma, polysubstance use, insecure housing, and seizure disorder presented to the emergency department with abdominal pain. His initial workup, including basic labs, lactic acid, and chest x-ray, was unremarkable. He received fluids, Droperidol and was discharged. Three days later, the patient returned with chest pain, shortness of breath, abdominal pain, generalized fatigue, and a new productive cough. Furthermore, he mentioned a severe (10/10) shooting pain his chest to his scrotum, across his shoulders and diffusely throughout his abdomen after smoking heroin three days prior.

In the emergency department, the patient was afebrile and hemodynamically stable. Laboratory findings demonstrated elevated lactic acid and troponins. Upon examination, he was found to have a bounding S1 and S2 with a holosystolic murmur at the left upper sternal border, and a visible and inferolaterally displaced point of maximal impulse. These findings prompted a transthoracic echocardiogram which showed pericardial effusion and a dissection flap. An emergent CT-Angiogram showed an Type A aortic dissection spanning from the ascending aorta to just proximal of the renal arteries. The patient subsequently underwent emergent surgical aortic dissection repair.

Discussion: Aortic dissection is commonly misdiagnosed, with 1/3rd of aortic dissection patients receiving an incorrect initial diagnosis. The case underscores the need for clinicians to consider AAD in patients presenting with acute chest pain, dyspnea, abdominal pain and scrotal pain, even in the absence of classic distress. Furthermore, the association between substance use, particularly heroin, and AAD warrants further investigation. Awareness of atypical presentations and a comprehensive diagnostic approach are crucial for timely identification and intervention in AAD cases.

Conclusion: This case report emphasizes the diagnostic challenges associated with atypical presentations of AAD. Clinicians should maintain a high level of suspicion, especially in patients with diverse symptomatology and risk factors. Further research is needed to explore the relationship between substance use, such as heroin, and the development of AAD. Timely recognition and intervention are pivotal for improving outcomes in this life-threatening condition.

References: Levy D, Goyal A, Grigorova Y, et al. Aortic Dissection. Updated 2023 Apr 23. In: StatPearls Internet. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Lovatt S, Wong CW, Schwarz K, et al. Misdiagnosis of aortic dissection: A systematic review of the literature. Am J Emerg Med. 2022;53:16-22.