Chest And Flank Pain

Hx: A 67 yo male complains of chest pain with shortness of breath. Pain is mid sternal pressure, non-radiating, and started this morning. There was some shortness of breath but it is better after a single nitro at home which he took about 4 hours ago. He also has left lateral chest pain/flank pain for 2 days that is separate, severe, worse with movement and inspiration, and not improved with nitro. He notes he had some chest pressure in the midsternal area a week ago which was brief and some left lower leg swelling for a week. No fever, diaphoresis, nausea, arm pain. Chest pressure currently 2/10. Left side chest/flank pain, sharp and 8/10 with inspiration.

PMHx:

• Coronary artery disease- stented 8 months ago
• Prostate cancer – treated with radiation, chemotherapy and surgery 7 years ago with normal bone scan and labs 1 month ago
• HTN
• Hyperlipedemia

SocHx: no tobacco, alcohol, drugs.

Meds: The patient was supposed to be on plavix but he stopped it one month after his stent due to non-compliance.

Exam:

• Vitals: HR 100, BP 160/90, Sat 95% RA, RR 18
• HEENT: normal Lungs: clear, shallow breaths due to flank pain.
• Cardiovascular: mild tachycardia, regular, normal pulses, no murmurs.
• Chest wall: no rashes, no tenderness, no crepitance.
• Abdomen: no tenderness, soft.
• Extremities: left lower leg 2+ pitting edema, right lower leg 1+ pitting edema, upper extremities normal.

Differential:

• ACS (AMI, unstable angina)
• PE
• Aortic Dissection
• CHF, new onset
• Chest Wall Pain
• Pyelonephritis
• Ureteral Colic

Diagnostics:

• ECG: RBBB (old), rate 100, no new ST changes.
• Chest Xray: normal
• CBC- white blood cell count 83,000, hemoglobin 9, platelets 77,000
• Complete metabolic is was normal
• D-Dimer is unmeasurably high
• Troponin is normal.
• CT Pulmonary Angiogram showed bilateral lower lobe pulmonary emboli with extensive DVT in the left lower extremity.

Hospital course:

The patient was admitted and started on a heparin infusion to treat his pulmonary emboli and DVT. After 24 hours of hemodynamic stability, he was transferred to a tertiary oncology center for induction chemotherapy with a preliminary diagnosis of acute leukemia.

Discussion:

Although this patient’s emergency department visit seemed straightforward, his ultimate diagnosis was unexpected. He presented with chest pain and flank pain associated with left lower leg swelling. This made the worry for pulmonary embolism high, in addition to ACS and possible aortic dissection or leaking aneurysm. However, his leukocytosis quickly changed the picture. Though he had normal outpatient testing as recently as one month ago, his current testing showed a dramatic change. In the setting of acute leukemia, his risk for DVT and pulmonary embolism was significantly higher. Although he had significant risk factors for ACS and a recent history of coronary stenting, his presentation and laboratory evaluation pointed to a different etiology, leukemia.

Despite the patient’s relative thrombocytopenia, there was still a need for anticoagulation. His platelet count was not low enough to put him at risk for life threatening spontaneous hemorrhage. However, a short acting and easily reversible agent was most suited for this scenario. Subsequently, a heparin infusion was chosen. Once the patient had proven hemodynamic stability, attention could be turned to his new diagnosis of leukemia. This required transport to an outside cancer center where the patient had received is prior care. There the patient was planned for bone marrow biopsy and ultimately induction chemotherapy in isolation. The patient’s prior history of chemotherapy and radiation for prostate cancer places him at increased lifetime risk of developing acute leukemia (typically myelogenous leukemia), colo-rectal and bladder cancers. In this case, the patient was asymptomatic until he developed complications of acute leukemia.

Further Reading:

http://sperlingprostatecenter.com/radiation-increases-leukemia-risk/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484296/

https://www.ncbi.nlm.nih.gov/pubmed/12696188

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3126090/

https://www.cancer.org/cancer/prostate-cancer/after-treatment/second-cancers.html

https://www.journeyforward.org/second-cancers-caused-prostate-cancer-treatment