Tuesday, March 3, 2009

Chest pain in a young woman- should be an easy one

It looked like an easy one for a change. I picked up the chart of my new patient- a 36 year old woman complaining of chest pain. She appeared to be a fit healthy woman in no obvious stress. Immediately, I began considering the differential diagnosis of chest pain in a young woman. The usual suspects quickly came to mind: chest wall strain, costochondritis- inflammation of the cartilage where the ribs join the sternum, a trapped gas bubble, stress/anxiety, lung infection- especially pleurisy, possible mitral valve prolapse, acid reflux disease and a few others. Coronary heart disease seemed quite unlikely. Pericarditis was near the bottom of my list.

I then took the patient's history. The pain had been present for two months, but recently- over the past one week, it had become more severe. It was constant and was located in the left chest area. It was not pleuritic (it did not increase with respiration). It did not radiate. It was not associated with sweating or shortness of breath. She did not have heartburn. The pain was not reproducible with pressure applied to the chest wall or with movements of her body. There was no history of trauma. These are standard doctor questions in the evaluation of chest pain.

What made the pain better or worse? The pain improved with aspirin and with leaning over. Interesting.

Oddly enough she complained of severe fatigue. She denied a history of a recent respiratory infection or viral syndrome.

And then oddly enough she complained of occasional night sweats over a period of two months corresponding to the time frame of the chest pain. I filed this away in my head.

Her history and exam were unremarkable. She had a mild systolic heart murmur but I thought it was within the normal range.

To be complete I performed an EKG: normal. I considered the fact that the pain decreased when she bent over. I recalled that pericarditis associated chest pain can improve with a change in position. Frequently bending forward makes it worse rather than better.

I have on site cardiac echo. To be thorough, I performed an echocardiogram.

The findings were surprising. There was fluid around the heart in the pericardial sack. This is compatible with the diagnosis of pericarditis. Frequently preicarditis in an otherwise healthy young woman is due to a viral infection and is self limiting. Of course there is a long list of disorders which may cause pericarditis, including: lupus and other autoimmune syndromes, tuberculosis, HIV, fungal infections, parasitic infections, bacterial infections, kidney disease, and unusual cardiac disorders. I also know that pericarditis can be a manifestation of Lyme disease. I ordered an anti inflammatory drug, Indocin assuming she had viral pericarditis.

As we were finishing up the visit I asked another question, as an after thought: Have you had any tick bites?

She answered: Yes, three years ago, it was a tiny tick and I could barely see it. I think there was a rash as well.

Pericarditis, fatigue, night sweats and a tick bite: I had to connect the dots- It looks like Lyme yet again.

8 comments:

bitten said...

For the rest of the 3 years was she asymptomatic? That would be scary for that to be your first symptom of Lyme or other tick borne disease. Is it a common symptom for Lyme or Bart or Babesia? What would have happened if she had not received treatment?

btb258 said...

What is your name doctor? I just randomly searched for articles linking Lyme and Head injuries and found your blog. It makes a lot of sense what you are saying.

I had a mild closed head injury and never recovered. The doctors didn't know why I didn't seem to recover all the MRIs didn't show much of anything. I was diagnosed with Lyme just recently but I know I acquired Lyme long before the head injury because I had many of the physiological symptoms slowly coming on years before the head injury caused everything to go haywire. We'll see if the antibiotics cause me to heal up like this lady-- that would be great!

I am currently seeing Dr. Fishman but if you wouldn't mind I may like to make an appt at your offices for a second opinion. My email is btb258@email.vccs.edu, I'm a student in Northern VA.

Thanks for writing this btw. It was very encouraging to me.

Lyme report: Montgomery County, MD said...

Lyme Western Blot back:
CDC positive for Lyme

konneker.blogspot.com said...

Dr,
I am a 17 year RN who was diagnosed with Lyme in May 2009. I completed 5 weeks of doxy followed by 3 IV rocephin when I began to have neuro symptoms. Here it is a year later and my doc abides strictly by the CDC guidelines. I want my life back, I want my career back. I currently suffer from daily fevers of up to 100.3, extreme joint pain/stiffness, bouts of confusion, extreme dizziness with sudden onset of vomiting, urinary hesitancy, new symptoms within the past two months an arrhythmia that comes and goes, while I break out into a sweat and my heart rate shoots up to 150, I feel as though I'm going to black out at that time. But then they pass. I do have an appt scheduled for and MRI/MRA on Friday and and rheumatolgist appt next thursday. Praying for help. Any advice? What should be my next step. I don't want to take long term axb if they don't help but feel like I'm doing nothing and getting worse. tkonneker@gmail.com

konneker.blogspot.com said...
This comment has been removed by the author.
aashvi said...

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shaheel said...

TREATMENT FOR CHEST PAIN
Chest pain is considered a chief symptom of heart related problems. It can occur due to various causes such as heart attack, pulmonary embolism, thoracic aortic dissection, oesophageal rupture, tension pneumothorax and cardiac tamponade.

By conducting several medical tests, the above causes could be ruled out or treated as recommended by medical professionals. If acute chest pain occurs, the patient should be admitted immediately for observation and sequential E.C.G.'s are followed up.

Just like in all medical cases, a careful medical history and detailed physical examination is essential in separating dangerous from minor/trivial causes of disease. Sometimes, there is need of rapid diagnosis to save life of patient. A deep study of recent health changes, family history, tobacco consumption, smoking, diabetes, eating disorders, etc. is useful in treatment of chest pain.

Features of chest pain could be generalised as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; pain coming from exertion; dizziness; shortness of breath and a sense of impending doom. On the basis of these characteristics, a number of tests can be carried out for proper treatment. X-ray and CT scan of the chest help in determining the basic cause of pain. An electrocardiogram helps in detailed study of the problem.

james mathew said...

Chest pain in young women occurs due to depression or Valvular Heart Disease.This causes may lead to the pain in chest.
Symptoms of Stroke