Physician Assistant
Board Review

Angina pectoris is chest pain caused by myocardial ischemia. It is typically described as a pressure or heaviness in the chest but may also be described as a squeezing or burning sensation. Pain typically develops with exertion or other causes of increased cardiac demand such as emotional excitement and stress. Pain often resolves with rest of 5 to 30 minutes, and pain that does not resolve with rest may indicate myocardial infarction. Nitroglycerin or other medications that improve oxygen delivery and lower oxygen demand often relieve the pain as well. The pain is most often located in the substernal anterior chest region and can radiate to the neck, jaw, shoulders, or arms. It rarely radiates below the umbilicus.

Other causes of chest pain can confound an accurate diagnosis and initiation of therapy for patients. Pericarditis occurs when the pericardium becomes inflamed. Pain is described as being located in the upper abdomen, tip of the shoulder, or even in the back. Pain is often exacerbated by respiratory movements such as coughing or deep inspiration, as well as by changes in body position such as when lying supine.

Pulmonary emboli cause chest pain that is thought to be from sudden increased pulmonary hypertension and distension of the pulmonary artery. Infarction of a lung segment can cause pain as well. The pain often has a pleuritic component. Large pulmonary emboli may center the pain substernally, but smaller emboli can cause lateral chest pain. Hemoptysis may be noted.

Esophageal reflux occurs when gastric contents reflux into the esophagus, causing irritation and possibly damage. The pain is described as deep thoracic burning in the center of the chest. Food and other irritants such as alcohol can exacerbate the pain. Acid-reducing therapies often improve the pain.

Costochondritis is an inflammation of the costochondral junction. It is the site of the most common cause of anterior chest wall pain. The joint between the sternum and the ribs can become inflamed and swollen in Tietze's syndrome. Pain can be sharp and pinpoint and exacerbated by chest wall movement or palpation of the affected joint space. Dull, aching pain is also described when adjacent muscles spasm from prolonged irritation.

Reference: Fauci AS, Braunwald E, eds. Harrison's Principles of Internal Medicine. 14th ed. McGraw-Hill; 1998 .

Reviewed in October 2011.

Educational Objective:

Discuss emergency management of central retinal vein occlusion.

Key Point:

Treatment of central retinal vein occlusion is done by the ophthalmologist, not the emergency physician.

Explanation:

Treatment of a central retinal vein occlusion may include lowering of intraocular pressure, application topical steroids, cyclocryotherapy, and photocoagulation. Central retinal vein occlusion with macular edema may also benefit from intra-ocular antivascular growth factor or Intra-vitreal injection of steroids. Recent studies also suggest some benefit from antithrombotic therapy with low-molecular-weight heparin, but overall, treatment attempts remain frustratingly unable to preserve vision. Prognosis mostly depends on the degree of vascular occlusion prior to treatment.

Breathing into a paper bag would dilate the central retinal artery, which would not benefit this situation.

References:

Guluma K, Lee JE. “Ophthalmology.” (Chapter 361) In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 790-819.e3.

Michael Vortmann, Jeffrey I. Schneider; “Acute Monocular Visual Loss”, Emergency Medicine Clinics of North America - Volume 26, Issue 1 (February 2008)

Based on the patient's complaint, a sexually transmitted disease seems likely. A painless, smooth-based penile ulcer characterizes primary syphilis, whereas the secondary stage is manifested by rash. Painless lymphadenopathy can also occur. Diagnosis is confirmed by VDRL, RPR, and FTA-ABS testing. Dark-field microscopy is the only way to visualize the organism. The Jarisch-Herxheimer reaction occurs 12 hours after treatment of syphilis and is manifested by fever and rash. It is self-limited. Patients are frequently not told about this reaction and may seek emergency treatment. Genital herpes simplex is usually associated with penile vesicles on an erythematous base. As the vesicles resolve, they frequently become unroofed and appear as small ulcers. Herpes is associated with generalized lymphadenopathy and flu-like symptoms.

Aspergillosis is caused by a mold found on decaying vegetation and in the soil. The principal route of transmission is inhalation.

Invasive pulmonary aspergillosis is the most common type of aspergillosis and is found in immunocompromised children. Invasive aspergillosis can also involve sinus, cerebral, cutaneous, cardiac, and orbital sites. A conclusive diagnosis of aspergillosis requires a culture; there is no pathognomonic study finding. Commonly, multiple nodules can be seen on x-ray. The halo sign is a classic finding on computed tomography but can also be seen in other pulmonary fungal infections.

Coccidioidomycosis is the only other fungus on the list and is rarely associated with lung lesions.

Treatment of aspergillosis normally involves an antifungal medication and discontinuation of corticosteroids to help establish normal immune function.

Reference: 

Gould JM, Aronoff SC. Histoplasmosis (Histoplasma capsulatum). In: Kliegman RM, et al. Nelson Textbook of Pediatrics. 19th ed., 2011:1062-1063.

Rogg LE, Steinbach WJ. Aspergillus. In: Kliegman RM, et al. Nelson Textbook of Pediatrics. 19th ed., 2011:1058-1061.

Weisse ME, Maranich AM. Malassezia. In: Kliegman RM, et al. Nelson Textbook of Pediatrics. 19th ed., 2011:1058.

This patient has Hantavirus pulmonary syndrome (HPS) caused by the Sin Nombre virus. Human infection occurs when a person inhales droplets of urine, saliva, or respiratory secretions from rodents. Ingesting food contaminated with rodent secretions or the contamination of cutaneous injuries have also been described.

Other hemorrhagic fevers, such as yellow and dengue fevers, may be transmitted via mosquitoes, but they will not be acquired in North America. Leptospirosis is transmitted by contact with water contaminated with animal urine, and it is common among athletes and adventure travelers. Histoplasmosis may be acquired by contact with bat droppings. Q fever and coccidioidomycosis can occur after a person inhales contaminated dust.

Sin Nombre is the prevalent virus that causes HPS in North America, whereas the Andes virus is more common in South America. The disease usually presents with a prodrome of fever and unspecific symptoms. It is then followed by rapidly progressive, noncardiogenic pulmonary edema and marked hemoconcentration, with a hemoglobin level around 20 mg/dL.

References:
Centers for Disease Control and Prevention. Update: outbreak of Hantavirus infection -- Southwestern United States, 1993. Morb Mortal Wkly Rep MMWR. 1993;42:477-479.
Centers for Disease Control and Prevention. Hantavirus Infection -Southwestern United States. Interim Recommendations for Risk Reduction. Morb Mortal Wkly Rep MMWR. 1993;42:1-13.