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Resident PGY 2
Henry Ford Macomb
Penetrating aortic ulcers (PAU) were recognized as a separate disease process from aortic dissection in 1986 and affects 0.6 - 2.1 in 100,000 people per year. It is estimated that 1 in 8 patients with penetrating aortic ulcers will progress to aortic dissections. Patients with PAUs often present with severe chest pain, severe back pain, shortness of breath and unstable vital signs, often mimicking aortic dissection or pulmonary embolism. This case report describes an unusual presentation of PAU and highlights the importance of maintaining a high index of suspicion for aortic syndromes. A 74-year-old female, with past medical history of anxiety, depression, hyperlipidemia and hypertension, presented to the Emergency Department due to a burning pain on her left shoulder. The pain started three days prior and did not radiate. She denied trauma to the area. It was not associated with fevers, chest pain, shortness of breath, weakness or rash. The patient noted that she was seeing an outpatient therapist for anxiety. She stated that “my family and doctors think I’m crazy and this is all in my head”. She admitted to weaning herself off of her psychiatric medications two weeks prior.On physical exam, the patient’s vital signs were all within normal limits apart from a slight bradycardia. The patient was not hypotensive, tachycardic or hypoxic. She was resting comfortably and in no acute distress. The remainder of her cardiac, pulmonary and neurologic exam was normal. The patient did not have a rash. Neither did she have calf tenderness or edema. She had full range of motion of her left shoulder and no tenderness to palpation. A cardiac workup was then preformed. Her EKG showed Sinus Bradycardia without ST elevations or T-wave inversions. Her lab work including CBC, BMP, and Troponin, revealed no major abnormalities. Given the normal physical exam, stable vital signs and benign laboratory results, it was thought that the patient may have been presenting with symptoms of a shingles rash that had not yet erupted. At this time, the patient was re-evaluated. Her vitals were stable and her exam remained unchanged. The patient also noted that her pain had improved with pain medication. However, in the course of our discussion, the patient stated that she “could not get comfortable”. The decision was then made to discontinue the patient’s discharge and to obtain a CTA of her chest to rule out aortic dissection. No aortic dissection or aneurysm was seen. However, the patient was found to have numerous penetrating aortic ulcers along the aortic arch. They ranged in size from small to large. The patient was also found to have small bilateral pulmonary embolisms. Cardiothoracic surgery was immediately consulted and the patient was placed on an Esmolol drip and on a heparin drip. Ultimately, the patient was admitted to the ICU for further monitoring. After being monitored for five days inpatient, with repeat imaging showing stable ulcerations, the patient was discharged home on Eliquis and anti-hypertensive medications. She did not require emergent surgical intervention.This case demonstrates that a seemingly benign and common symptom, such as shoulder pain, can ultimately be the only presenting sign of a life-threatening diagnosis. All physicians must maintain a high degree of suspicion, particularly in the ED setting. This case also demonstrates the dangers of anchoring bias. Had we anchored ourselves on the shingles diagnosis and discharged the patient upon a normal reassessment, we would have missed two life threatening diseases.
Ward, Samantha and Waterfield, Abby, "An Unusual Presentation of Penetrating Aortic Ulcers, A Case Report" (2019). Case Reports. 105.