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Aortic Dissection Presenting as “Hysteria”
The Journal of Emergency Medicine, Vol. 49, No. 5, pp. 627–629, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.05.039
Clinical Communications: Adults AORTIC DISSECTION PRESENTING AS ‘‘HYSTERIA’’ Thilo Witsch, MD,* Anna Stephan, MD,† Petra Hederer, MD,‡ Hans-Joerg Busch, MD,‡ and Jens Witsch, MD§ *Department of Cardiology and Angiology I, †Department of Cardiology and Angiology II, University of Freiburg, Heart Center, Freiburg, Germany, ‡Emergency Department, University Hospital Freiburg, Freiburg, Germany, and §Division of Critical Care Neurology, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, USA Reprint Address: Thilo Witsch, MD, Universita¨ts-Herzzentrum Freiburg - Bad Krozingen, Hugstetter Straße 55, Freiburg 79106, Germany
, Abstract—Background: Patients with medical conditions may present with psychiatric symptoms, which may lead to worse physical health care. Here we present the case of a patient with acute aortic dissection masked by psychiatric symptoms after a stressful event. Case Report: A 29year-old female medical student presented to the Emergency Department (ED) complaining about the feeling of ‘‘hysteria’’ after an argument with her boyfriend earlier the same day. She did not report other symptoms or pain. Careful physical examination, initially impeded by the patient’s agitation, revealed pulseless extremities. Blood gas analysis showed metabolic acidosis. Transthoracic echocardiography and computed tomography ultimately led to the correct diagnosis: Stanford Type-A aortic dissection. Why Should an Emergency Physician Be Aware of This?: Medical conditions requiring acute diagnostic work-up and therapy may present with psychiatric symptoms. Increased awareness and the use of standardized operating procedures in the ED may prevent fatal misdiagnoses in these patients. Ó 2015 Elsevier Inc.
In this cohort the most common symptoms among patients with a medical condition were depression, confusion, anxiety, speech, and memory disorders (1). It has been shown that patients with a known mental illness receive worse health care, even when presenting to the emergency department (ED) with physical symptoms. Hypothetically, this may partly be the result of an attribution of physical symptoms to the known mental illness, so-called ‘‘diagnostic overshadowing’’ (2,3). However, few data exist on quality of health care and outcomes in patients without past history of mental illness who present to the ED with psychiatric symptoms. Here we report a case of a patient with aortic dissection presenting with agitation, which was initially attributed to a psychiatric condition. CASE REPORT A 29-year-old previously healthy female medical student was admitted to our ED for a ‘‘nervous breakdown.’’ On arrival, the patient was considerably agitated and uncooperative, which hindered taking a detailed medical history and physical examination. She could report that she had an emotional but nonviolent argument with her boyfriend earlier that day and that she felt ‘‘hysterical,’’ as she described it. Moreover, the patient complained of persisting nonspecific general discomfort, tingling and mild numbness of both hands and feet. The onset of symptoms, as
, Keywords—aortic dissection; panic disorder; neurological symptoms; blood gas analysis
INTRODUCTION Medical conditions presenting with psychiatric symptoms are frequent, occurring in 9% of patients as assessed in a psychiatric outpatient cohort of 658 patients.
RECEIVED: 8 January 2015; FINAL SUBMISSION RECEIVED: 14 May 2015; ACCEPTED: 29 May 2015 627
628
T. Witsch et al.
Figure 1. Computed tomography scan of the thorax and neck. (A1) Type A aortic dissection with dissecting membrane in the aneurysmatic ascending (red arrows) and descending aorta (black arrows). Red arrows are located in the true lumen, black arrows in the false lumen. (A2) Sagittal view of the descending aorta showing dissecting membrane (black arrows). The white horizontal line indicates the plane of the axial view shown in A1. (B) Reconstruction of the aortic arch and supraaortic branches: dissecting membrane extending into the right CCA (red arrow) and the outflow of the left CCA. CCA = common carotid artery. (Color version of the figure is available online.)
she recalled, had not been sudden. She denied experiencing pain. The patient had no history of mental illness. The cursory neurologic examination was unremarkable; however, in-depth examination of sensation was not feasible. Vital sign measurements revealed sinus tachycardia (100 beats/min) and tachypnea (30 breaths/min). Attempts to measure blood pressure and peripheral O2saturation failed, which was initially thought to be due to the patient’s restlessness. An electrocardiogram was unremarkable. To treat hyperventilation, the patient back-breathed into a plastic bag. In addition she was given 2 mg sublingual lorazepam. A psychiatric consult
was requested for a suspected panic disorder with hyperventilation. Slightly cyanotic lips, pale complexion, and mottled hands were then noted, and raised first doubts regarding a psychiatric etiology of symptoms. Venous blood gas analysis (BGA) yielded mild acidosis (pH 7.23), normal ionized calcium (1.2 mmol/L), and elevated lactate (6.4 mmol/L), all inconsistent with hyperventilation syndrome. When closer physical examination was possible, it revealed pulselessness of all four extremities. Pulse could be palpated only over the left carotid artery. Heart auscultation revealed a 2/6 diastolic murmur. Bedside
Aortic Dissection Presenting as ‘‘Hysteria’’
transthoracic echocardiography revealed a second-degree central aortic regurgitation as a consequence of an aneurysmatic ascending aorta, measuring 52 mm in diameter. These findings were suggestive of aortic dissection. Contrast computed tomography of the aorta and its branches demonstrated a Stanford-Type-A dissection (Figure 1) affecting the entire aorta and extending from the aortic valve level into the right common carotid artery (CCA) and both iliac arteries. Both subclavian arteries were occluded by thrombi. The patient was transferred to the cardiovascular operating room, where a valve-sparing replacement of the aortic root and arch was performed without complications. The patient recovered quickly from surgery and was discharged home 19 days after admission. Postoperatively, it was disclosed that the patient’s mother had had an aortic dissection at age 40 years. Pathological assessment of the patient’s aorta was, in principle, compatible with cystic medial degeneration Erdheim-Gsell, although the medial necrosis had an atypical morphology. Spiral vessels, typical for Loeys-Dietz syndrome, could not be detected. Genetic testing, specifically for Marfan and Loeys-Dietz syndromes, was not desired by the patient at this point. The patient exhibited no clinical features compatible with any of the considered diagnoses. The patient’s only vascular risk factor was a history of smoking. One month after discharge, a follow-up computed tomography scan of the neck showed a persistent but stable dissecting membrane in the right CCA and reperfused subclavian arteries. The patient was symptom-free on follow-up 49 days after discharge and no psychiatric symptoms had reoccurred. DISCUSSION Type-A aortic dissection most commonly presents with intense chest pain (4). Ninety-three percent of patients with aortic dissection report some kind of pain as one of their symptoms (5). Paresthesia in extremities may occur when the supplying arterial branches are blocked by the dissecting membrane. However, these sensory symptoms are relatively rare in the event of aortic dissection (6). In the presented case, a preceding stressful event with subsequent hyperventilation described as a ‘‘hysterical’’ reaction, combined with the patient’s young age, symmetry of paresthesia, and absence of chest pain were initially misguiding, and may have led to a fatal misinterpretation of symptoms as hyperventilation related. It was, foremost, the rather subtle alterations of venous BGA that
629
indicated that the patient’s condition was unlikely to be a psychiatric disorder. Conditions requiring emergency treatment may be missed in cases of atypical presentation, especially when initial symptoms are psychiatric ones (7,8). This may be a problem, particularly in the ED setting, where patients are often first seen by relatively inexperienced residents that primarily rely on textbook information for clinical decision-making. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Young agitated patients with nonspecific symptoms, like tingling of the extremities, are frequently seen in EDs and are easily labeled ‘‘psychogenic.’’ Yet, acute physical illnesses may present with psychiatric symptoms and must always be taken into account. Thorough physical examination and attention to simple standard diagnostic procedures like BGA are the first steps to avoiding fatal misdiagnoses and administering timely medical care in the ED. Acknowledgments—T.W. is a recipient of a fellowship of the German Cardiac Society (Deutsche Gesellschaft fu¨r Kardiologie). J.W.’s work was supported by Deutsche Forschungsgemeinschaft (research scholarship Wi 4300/1-1).
REFERENCES 1. Hall RC, Popkin MK, Devaul RA, Faillace LA, Stickney SK. Physical illness presenting as psychiatric disease. Arch Gen Psychiatry 1978;35:1315–20. 2. Jones S, Howard L, Thornicroft G. ‘Diagnostic overshadowing’: worse physical health care for people with mental illness. Acta Psychiatr Scand 2008;118:169–71. 3. Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms – a qualitative study. PLoS One 2014;9:e111682. 4. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903. 5. Raghupathy A, Nienaber CA, Harris KM, et al. Geographic differences in clinical presentation, treatment, and outcomes in type A acute aortic dissection (from the International Registry of Acute Aortic Dissection). Am J Cardiol 2008;102:1562–6. 6. Spittell PC, Spittell JA, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993;68:642–51. 7. Schlicht KF, Mann K, Jungmann F, et al. A 48-year-old woman with panic attacks. Lancet 2014;384:280. 8. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and ‘‘hysteria’’ BMJ 2005;331:989.
http://dx.doi.org/10.1016/j.jemermed.2015.05.039
Clinical Communications: Adults AORTIC DISSECTION PRESENTING AS ‘‘HYSTERIA’’ Thilo Witsch, MD,* Anna Stephan, MD,† Petra Hederer, MD,‡ Hans-Joerg Busch, MD,‡ and Jens Witsch, MD§ *Department of Cardiology and Angiology I, †Department of Cardiology and Angiology II, University of Freiburg, Heart Center, Freiburg, Germany, ‡Emergency Department, University Hospital Freiburg, Freiburg, Germany, and §Division of Critical Care Neurology, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, USA Reprint Address: Thilo Witsch, MD, Universita¨ts-Herzzentrum Freiburg - Bad Krozingen, Hugstetter Straße 55, Freiburg 79106, Germany
, Abstract—Background: Patients with medical conditions may present with psychiatric symptoms, which may lead to worse physical health care. Here we present the case of a patient with acute aortic dissection masked by psychiatric symptoms after a stressful event. Case Report: A 29year-old female medical student presented to the Emergency Department (ED) complaining about the feeling of ‘‘hysteria’’ after an argument with her boyfriend earlier the same day. She did not report other symptoms or pain. Careful physical examination, initially impeded by the patient’s agitation, revealed pulseless extremities. Blood gas analysis showed metabolic acidosis. Transthoracic echocardiography and computed tomography ultimately led to the correct diagnosis: Stanford Type-A aortic dissection. Why Should an Emergency Physician Be Aware of This?: Medical conditions requiring acute diagnostic work-up and therapy may present with psychiatric symptoms. Increased awareness and the use of standardized operating procedures in the ED may prevent fatal misdiagnoses in these patients. Ó 2015 Elsevier Inc.
In this cohort the most common symptoms among patients with a medical condition were depression, confusion, anxiety, speech, and memory disorders (1). It has been shown that patients with a known mental illness receive worse health care, even when presenting to the emergency department (ED) with physical symptoms. Hypothetically, this may partly be the result of an attribution of physical symptoms to the known mental illness, so-called ‘‘diagnostic overshadowing’’ (2,3). However, few data exist on quality of health care and outcomes in patients without past history of mental illness who present to the ED with psychiatric symptoms. Here we report a case of a patient with aortic dissection presenting with agitation, which was initially attributed to a psychiatric condition. CASE REPORT A 29-year-old previously healthy female medical student was admitted to our ED for a ‘‘nervous breakdown.’’ On arrival, the patient was considerably agitated and uncooperative, which hindered taking a detailed medical history and physical examination. She could report that she had an emotional but nonviolent argument with her boyfriend earlier that day and that she felt ‘‘hysterical,’’ as she described it. Moreover, the patient complained of persisting nonspecific general discomfort, tingling and mild numbness of both hands and feet. The onset of symptoms, as
, Keywords—aortic dissection; panic disorder; neurological symptoms; blood gas analysis
INTRODUCTION Medical conditions presenting with psychiatric symptoms are frequent, occurring in 9% of patients as assessed in a psychiatric outpatient cohort of 658 patients.
RECEIVED: 8 January 2015; FINAL SUBMISSION RECEIVED: 14 May 2015; ACCEPTED: 29 May 2015 627
628
T. Witsch et al.
Figure 1. Computed tomography scan of the thorax and neck. (A1) Type A aortic dissection with dissecting membrane in the aneurysmatic ascending (red arrows) and descending aorta (black arrows). Red arrows are located in the true lumen, black arrows in the false lumen. (A2) Sagittal view of the descending aorta showing dissecting membrane (black arrows). The white horizontal line indicates the plane of the axial view shown in A1. (B) Reconstruction of the aortic arch and supraaortic branches: dissecting membrane extending into the right CCA (red arrow) and the outflow of the left CCA. CCA = common carotid artery. (Color version of the figure is available online.)
she recalled, had not been sudden. She denied experiencing pain. The patient had no history of mental illness. The cursory neurologic examination was unremarkable; however, in-depth examination of sensation was not feasible. Vital sign measurements revealed sinus tachycardia (100 beats/min) and tachypnea (30 breaths/min). Attempts to measure blood pressure and peripheral O2saturation failed, which was initially thought to be due to the patient’s restlessness. An electrocardiogram was unremarkable. To treat hyperventilation, the patient back-breathed into a plastic bag. In addition she was given 2 mg sublingual lorazepam. A psychiatric consult
was requested for a suspected panic disorder with hyperventilation. Slightly cyanotic lips, pale complexion, and mottled hands were then noted, and raised first doubts regarding a psychiatric etiology of symptoms. Venous blood gas analysis (BGA) yielded mild acidosis (pH 7.23), normal ionized calcium (1.2 mmol/L), and elevated lactate (6.4 mmol/L), all inconsistent with hyperventilation syndrome. When closer physical examination was possible, it revealed pulselessness of all four extremities. Pulse could be palpated only over the left carotid artery. Heart auscultation revealed a 2/6 diastolic murmur. Bedside
Aortic Dissection Presenting as ‘‘Hysteria’’
transthoracic echocardiography revealed a second-degree central aortic regurgitation as a consequence of an aneurysmatic ascending aorta, measuring 52 mm in diameter. These findings were suggestive of aortic dissection. Contrast computed tomography of the aorta and its branches demonstrated a Stanford-Type-A dissection (Figure 1) affecting the entire aorta and extending from the aortic valve level into the right common carotid artery (CCA) and both iliac arteries. Both subclavian arteries were occluded by thrombi. The patient was transferred to the cardiovascular operating room, where a valve-sparing replacement of the aortic root and arch was performed without complications. The patient recovered quickly from surgery and was discharged home 19 days after admission. Postoperatively, it was disclosed that the patient’s mother had had an aortic dissection at age 40 years. Pathological assessment of the patient’s aorta was, in principle, compatible with cystic medial degeneration Erdheim-Gsell, although the medial necrosis had an atypical morphology. Spiral vessels, typical for Loeys-Dietz syndrome, could not be detected. Genetic testing, specifically for Marfan and Loeys-Dietz syndromes, was not desired by the patient at this point. The patient exhibited no clinical features compatible with any of the considered diagnoses. The patient’s only vascular risk factor was a history of smoking. One month after discharge, a follow-up computed tomography scan of the neck showed a persistent but stable dissecting membrane in the right CCA and reperfused subclavian arteries. The patient was symptom-free on follow-up 49 days after discharge and no psychiatric symptoms had reoccurred. DISCUSSION Type-A aortic dissection most commonly presents with intense chest pain (4). Ninety-three percent of patients with aortic dissection report some kind of pain as one of their symptoms (5). Paresthesia in extremities may occur when the supplying arterial branches are blocked by the dissecting membrane. However, these sensory symptoms are relatively rare in the event of aortic dissection (6). In the presented case, a preceding stressful event with subsequent hyperventilation described as a ‘‘hysterical’’ reaction, combined with the patient’s young age, symmetry of paresthesia, and absence of chest pain were initially misguiding, and may have led to a fatal misinterpretation of symptoms as hyperventilation related. It was, foremost, the rather subtle alterations of venous BGA that
629
indicated that the patient’s condition was unlikely to be a psychiatric disorder. Conditions requiring emergency treatment may be missed in cases of atypical presentation, especially when initial symptoms are psychiatric ones (7,8). This may be a problem, particularly in the ED setting, where patients are often first seen by relatively inexperienced residents that primarily rely on textbook information for clinical decision-making. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Young agitated patients with nonspecific symptoms, like tingling of the extremities, are frequently seen in EDs and are easily labeled ‘‘psychogenic.’’ Yet, acute physical illnesses may present with psychiatric symptoms and must always be taken into account. Thorough physical examination and attention to simple standard diagnostic procedures like BGA are the first steps to avoiding fatal misdiagnoses and administering timely medical care in the ED. Acknowledgments—T.W. is a recipient of a fellowship of the German Cardiac Society (Deutsche Gesellschaft fu¨r Kardiologie). J.W.’s work was supported by Deutsche Forschungsgemeinschaft (research scholarship Wi 4300/1-1).
REFERENCES 1. Hall RC, Popkin MK, Devaul RA, Faillace LA, Stickney SK. Physical illness presenting as psychiatric disease. Arch Gen Psychiatry 1978;35:1315–20. 2. Jones S, Howard L, Thornicroft G. ‘Diagnostic overshadowing’: worse physical health care for people with mental illness. Acta Psychiatr Scand 2008;118:169–71. 3. Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms – a qualitative study. PLoS One 2014;9:e111682. 4. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903. 5. Raghupathy A, Nienaber CA, Harris KM, et al. Geographic differences in clinical presentation, treatment, and outcomes in type A acute aortic dissection (from the International Registry of Acute Aortic Dissection). Am J Cardiol 2008;102:1562–6. 6. Spittell PC, Spittell JA, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc 1993;68:642–51. 7. Schlicht KF, Mann K, Jungmann F, et al. A 48-year-old woman with panic attacks. Lancet 2014;384:280. 8. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and ‘‘hysteria’’ BMJ 2005;331:989.