Chest Pain - Case 14-4: 17-Year-Old Boy
I. History of Present Illness
A 17-year old boy presented with left-sided chest pain. He was well until 8 days
before presentation, when he developed left axillary and shoulder pain. The
pain was worse with inspiration. He denied fever, nausea, vomiting, and
diarrhea. He reported that he had had rhinorrhea and a dry cough 2 weeks
earlier. He had mild shortness of breath with exercise. He had no history of
trauma.
II. Past Medical History
He had a history of depression with no history of suicide attempts. He denied a
history of asthma or other chronic illnesses. His family and social histories
were noncontributory. He denied any drug use but did admit to having smoked
cigarettes in the past.
III. Physical Examination
T, 36.6°C; RR, 18 to 20/min; HR, 108 bpm; BP, 120/60 mm Hg; SpO2, 95% in room air
Weight, 50th to 75th percentile; height, 75th to 90th percentile
In general, he was in no acute respiratory distress. His chest examination
revealed no chest wall deformity, and the chest was nontender to palpation.
Breath sounds were decreased at the bases, left greater than right. No wheezes
or rales were appreciated. His cardiac examination revealed normal S1 and S2,
with no murmurs, rubs, or gallops heard. The remainder of his physical
examination was normal.
IV. Diagnostic Studies
A complete blood count revealed 5,600 WBCs/mm3, with 55% segmented neutrophils, 31% lymphocytes, 11% monocytes, and 3%
eosinophils. Electrolytes were normal.
V. Course of Illness
A chest roentgenogram was considered diagnostic (Fig. 14-3).
Discussion: Case 14-4
I. Differential Diagnosis
The differential diagnosis for chest pain in this adolescent boy focused on the
acute nature of his pain. In general, the most common causes for chest pain in
the adolescent age group are psychogenic pain, cough, asthma, musculoskeletal
pain, and pneumonia. These causes most often produce a subacute and subtle type
of chest pain.
Therefore, the acute onset of chest pain in this boy should focus the
differential diagnosis on a number of other causes. Certainly, tobacco use or
the abuse of cocaine or methamphetamine could cause the acute onset of chest
pain secondary to vasospasm of the coronary arteries. Pneumothorax or
pneumomediastinum commonly manifest with the acute onset of chest pain. Some
abdominal processes, such as pancreatitis or cholecystitis, may manifest with
acute chest pain. Cardiovascular causes are less common but are
life-threatening. With acute chest pain, one should consider coronary artery
disease, arrhythmias, structural cardiac defects, and infections.
II. Diagnosis
A chest roentgenogram revealed a left pneumothorax (Fig. 14-3). The diagnosis is left spontaneous pneumothorax.
III. Incidence, Epidemiology and Pathophysiology
Pneumothoraces are divided into three groups: spontaneous, traumatic, and
iatrogenic. Spontaneous pneumothoraces can be either primary, in which there is
no underlying lung disease, or secondary, in which underlying lung pathology is
present. The incidence of primary spontaneous pneumothorax ranges between 7.4
and 18 cases per 100,000 males and between 1.2 and 6 cases per 100,000 females.
It is most common in tall, thin males between 10 and 30 years of age. Cigarette
smoking increases the risk of developing a primary spontaneous pneumothorax in
a dose-dependent fashion.
Secondary spontaneous pneumothoraces occur in patients with underlying lung
disease. The major causes include airways disease (e.g., cystic fibrosis),
infection (e.g.,
Pneumocystis carinii pneumonia), interstitial lung disease, connective tissue disease, malignancy,
and thoracic endometriosis. The incidence of secondary spontaneous pneumothorax
is 6.3 cases per 100,000 males and 2 cases per 100,000 females. Secondary
spontaneous pneumothoraces have a later peak incidence, at 60 to 65 years of
age.
Subpleural bullae are seen in 76% to 100% of children who are taken to
video-assisted thoracoscopic surgery. There is some speculation as to the
mechanism of bullae formation. It is likely that elastic fibers are degraded in
the lung, which ultimately leads to an imbalance in the protease/antiprotease
system and the development of bullae. A pneumothorax then develops as alveolar
pressure increases and air subsequently leaks into the interstitium.
IV. Clinical Presentation
Primary spontaneous pneumothorax usually develops while the patient is at rest.
Patients describe pleuritic ipsilateral chest pain and dyspnea. With a small
pneumothorax, the physical examination may be completely normal. Tachycardia
may be noted. In patients with a large pneumothorax, there may be poor chest
wall movement, a hyperresonant chest, and decreased breath sounds on the side
with the pneumothorax. Tachycardia and hypotension indicate that the patient
has developed tension physiology and requires emergency intervention.
With a large pneumothorax, the patient develops decreased vital capacity and an
increased alveolar
–arterial oxygen gradient. In patients with primary spontaneous pneumothoraces,
the underlying lung function is normal; therefore, they do not develop
hypercapnia. In contrast, patients with secondary spontaneous pneumothoraces by
definition have underlying lung disease and often develop hypercapnia.
V. Diagnostic Approach
Chest roentgenogram. A posterior-anterior chest roentgenogram reveals the presence of a pneumothorax.
Small apical pneumothoraces may be difficult to detect in this fashion, and on
occasion an expiratory roentgenogram is necessary.
Chest computed tomography. A chest CT scan may be necessary to differentiate a bulla from a pneumothorax.
VI. Treatment
A variety of treatment options exist for management of a pneumothorax, ranging
from observation to simple aspiration with a catheter, chest tube insertion,
pleurodesis, thoracoscopy with a single port, video-assisted thoracoscopic
surgery, and thoracotomy.
Patients with small primary spontaneous pneumothoraces may be observed without
intervention if there is no respiratory distress. They may be treated with
supplemental oxygen to hasten the reabsorption of air. With supplemental
oxygen, the air is reabsorbed at a rate of 2% per day. With larger primary
spontaneous pneumothoraces, needle aspiration or chest tube insertion is
required. Secondary spontaneous pneumothoraces are likely to require
intervention, because patients are usually ill due to their underlying lung
disease.
The main debate with spontaneous pneumothoraces is the ability to prevent
recurrences. With a primary spontaneous pneumothorax, the recurrence rate is
about 30%, and most recur 6 months to 2 years after the initial event. Smoking
and younger age are risk factors for recurrent disease. The recurrence rate
with secondary spontaneous pneumothoraces is similar at 39% to 47%.
The general consensus is to recommend preventative therapy after the second
ipsilateral pneumothorax. However, patients who participate in risky activities
such as scuba diving or flying should be considered for intervention after
their first spontaneous pneumothorax. Options for recurrence prevention include
the instillation of sclerosing agents through a chest tube and mechanical
pleurodesis. With video-assisted thoracoscopic procedures, blebs can also be
identified and oversewn.
VII. References
1. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous
pneumothorax: an American College of Chest Physicians Delphi Consensus
Statement.
Chest 2001;119:590–602.
2. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000;342:868–874.
3. Weissberg D, Refaely Y. Pneumothorax: experience with 1,199 patients. Chest 2000;117:1279–1285.
4. Montgomery M. Air and liquid in the pleural space. In: Chernick V, Boat TF,
eds.
Kendig's disorders of the respiratory tract in children. Philadelphia: WB Saunders, 1998:403–409.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Chest pain
» Next page: Chest Pain - Case 14-5: 3-Year-Old Girl (Pediatric Complaints and Diagnostic Dilemmas)
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