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Table of Contents
CLINICO-PATHOLOGICAL PEARLS
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 212-214

Type B aortic dissection presenting as a left-sided hemothorax in a patient with a low-risk probability


Department of Medicine, Farwaniya Hospital, Ministry of Health in, Kuwait

Date of Submission11-Oct-2020
Date of Decision12-Dec-2020
Date of Acceptance18-Jan-2021
Date of Web Publication13-Apr-2021

Correspondence Address:
Abduluah Alramyan
Department of medicine, Farwaniya hospital, Ministry of health in Kuwait
Kuwait
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_129_20

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  Abstract 


The differential diagnosis of isolated pleural effusion is very wide. Unilateral hemothorax carry the same wide differentials. Taking systematic approach can lead to diagnosis in the majority of cases. We presented a case of unilateral hemothroax in a gentleman with minimal symptoms and unhelpful clinical exam. Despite his low risk, he turned to have type B aortic dissection presenting as left sided hemothorax, which is a rare presentation. We presented the clinical course the patient went through and finished with brief discussion on thoracic aortic dissection and its relation to hemothorax.

Keywords: Pleural effusion, respiratory, vascular


How to cite this article:
Alramyan A, Alkhalifah F. Type B aortic dissection presenting as a left-sided hemothorax in a patient with a low-risk probability. J Nat Sci Med 2021;4:212-4

How to cite this URL:
Alramyan A, Alkhalifah F. Type B aortic dissection presenting as a left-sided hemothorax in a patient with a low-risk probability. J Nat Sci Med [serial online] 2021 [cited 2021 Jun 13];4:212-4. Available from: https://www.jnsmonline.org/text.asp?2021/4/2/212/313642




  Introduction Top


Aortic dissection is a serious and sometimes fatal disease. Therefore early recognition and accurate diagnosis is of paramount importance.[1] Aortic dissections are categorized into two types: type B dissection involves a tear in the descending part of the aorta and can extend into the abdomen, whereas type A dissection develops in the ascending part of the aorta just as it branches off the heart.[2] Chest pain of tearing quality is the most common presentation of both types of aortic dissection. The most prevalent risk factor in these patients is elevated blood pressure.[3]

In this article, we presented a case of a rare clinical presentation of aortic dissection in a patient with relatively low risk of having this disease. We outlined the diagnostic approach taken to evaluate this patient and what treatment has been offered. We stressed on the attentive consideration of lateral thinking and expanding the list differential diagnoses in patients presenting with uncommon presentation of a serious disease.


  Case Report Top


A 61-year-old male presented to the casualty with a 1-week long history of fever, productive cough, and dyspnea on exertion not responding to a 5-day clarithromycin course. In addition, he complained of a 2-day long history of left-sided pleuritic chest pain that was moderate in nature and alleviated slightly with analgesia.

The patient is known hypertensive but not on medications. He is a smoker with more than 5-pack per year history of smoking. He drinks occasionally. His family history is significant for stroke affecting his father at an old age.

Physical examination revealed that the patient was alert and oriented. His temperature was 37.2°C. His pulse was 92 and equal bilaterally. His blood pressure was 116/72 setting and 110/68 standing. His chest examination was significant for reduced air entry on the left side, with bilateral wheeze and crackles. The rest of cardiovascular, abdominal, neurological, and musculoskeletal components were unremarkable.

Investigation

His full blood count showed leukocytosis and anemia [Table 1]. His troponin was raised. His procalcitonin test (PCT) was high. His creatinine was high, but his urea was within normal limit. His liver function test was within normal. His chest X-ray [Figure 1] showed left-sided pleural effusion, tracheal deviation, and mildly enlarged mediastinum.
Table 1: Shows Two different CT-scan cuts of the patient. (a) evidence of leak into the left pleural space. (b) The diameter of the Aorta is enlarged suggesting intramural hematoma due to the presence of Aortic dissection.

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Figure 1: The admission chest X-ray of the patient with evidence of left pleural effusion and left tracheal deviation

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On admission, the hospital pulmonology team was consulted. They advised for computed tomography (CT) chest [Figure 2] with contrast and diagnostic pleural aspiration [Table 2]. Diagnostic pleural aspiration showed hemothorax with high pleural hematocrit (Hct) to serum Hct >0.5. The underlying cause for his isolated left hemothorax was not apparent at that stage, so the plan was to proceed for contrast-enhanced CT of the chest to evaluate more for the cause. The CT chest was done and showed two fusiform dilatations of the aorta with proximal one in the chest with intramural hematoma, suggesting the presence of thoracic aortic dissection. There is contrast leaking into the left pleural space, suggesting left hemothorax secondary to aortic dissection.
Table 2: shows the admission labs of our patient. There was 1 gram drop in haemoglobin and about 30% increase in Creatinine level. Cr: Creatinine, U: Urea, P: Phosphorus, PCT: Procalcitonin test, HB: Hemoglobin, PLT: Platelet, WBC: White cell count, LFT: Liver function test, HbA1c: Hemoglobin A1C, LDL: Low density lipoprotein, HDL: High density lipoprotein, TG: Triglyceride, INR: International normalized ratio, APTT: activated partial thromboplastin time.

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Figure 2: Two different CT-scan cuts of the patient. (a) evidence of leak into the left pleural space.(b) The diameter of the Aorta is enlarged suggesting intramural hematoma due to the presence of Aortic dissection

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The vascular team was consulted. Strict blood pressure and heart rate control with labetalol was advised. The patient was transferred to the operating theater on the same day, and an endovascular repair with a stent was performed [Figure 3]. The patient stayed in the intensive care unit for 2 days and then moved to the ward. Within few days, the patient was discharged home with no immediate complications. He was advised to follow-up in 3 months with vascular team in the outpatient clinic.
Figure 3: Aortic stent placed using endo-vascular repair technique (Courtesy of Dr. Ahmad Amir)

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What is the diagnosis?

Type B Aortic dissection presenting as a left sided hemothorax in a patient with a low risk probability.


  Discussion Top


Thoracic aortic dissection is a potentially fatal disease with an incidence of 3 in 100,000.[1] It is thrice as common in males and peaks during wintertime.[1] It is commonly classified using the Stanford system (used here) or DeBakey classification. A patient has type A dissection if the ascending aorta is involved. However, those with type B have dissection distal to the left subclavian artery.[2] Not only is type A more common than type B, but it is also more serious with an effect extending into the heart, pericardium, and nervous system. Such patients might suffer from tearing chest pain and newly developed murmur, neurological deficits, and myocardial infarction.[3] Hemothorax is quite a rare presentation and tends to be more common on the left side; however, a right-sided presentation has been documented in some studies.[4] Interestingly, our patient did not have any of the typical symptoms of aortic dissection, which makes the diagnosis unlikely at first glance. His chest pain was pleuritic and not tearing; there was no pulse deficit or neurological deficits. He did not have any of the high-risk conditions that cause aortic dissection either. His score is zero on the aortic dissection detection risk scoring system (ADD-RS). Along with his high D-dimer, the probability of him having aortic dissection was 4.3%.[5]

Although hemothorax has been more commonly reported in type B dissection, one study presented a case of hemothorax secondary to type A dissection.[6] Pleural aspiration in this case was done before CT chest, which showed hemothorax with pleural Hct to serum Hct >0.5. Initially, the underlying cause for the hemothorax was not apparent, until CT chest confirmed the aortic dissection leading to left-sided hemothorax.

In terms of risk factors for developing aortic dissection, age and hypertension seem to be present in most cases of aortic dissection. Other risk factors for thoracic dissection include family history, chest trauma, bicuspid valve, Ehlers Danlos, Marfan's syndrome, and Turner's syndrome.[3]

The modality of imaging used to diagnose aortic dissection depends on the hemodynamic stability of the patient. transesophageal ECHO is the preferred modality in hemodynamically unstable patients. However, as in our patient, who was hemodynamically stable a CT aortography is preferred since it is less operator dependent.[7]

The treatment of aortic dissection depends on the type. Patients with type A aortic dissection need urgent surgical intervention.[8] Those with type B dissection can be treated medically first. In these patients, surgery is only indicated if complications occur.[8] Our patient had evidence of leaking from the dissecting aorta in the chest CT scan, so the plan was to proceed for endovascular repair. Endovascular repair has been compared with open surgical repair in multiple studies.[9] The short-term and long-term outcomes appear comparable with a trend to reduce morbidity and mortality in the endovascular repair group.[9]

The prognosis of aortic dissection is better after surgery with a survival rate ranging from 55% to 70%. Those who are left untreated have a mortality rate of 1% per hour.[10]

Final diagnosis

Left hemothorax caused by type B aortic dissection in low-risk category patient.

Clinicopathological pearls

  1. Type B aortic dissection could present with isolated left or right hemothorax
  2. Even if the patient carries a low risk in the ADD-RS, vigilant look for aortic dissection is warranted if applicable findings from history, examination, and investigations are present
  3. Mortality of aortic dissection is high, so early prompt diagnosis is essential in patient with typical or atypical presentations.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bickerstaff LK, Pairolero PC, Hollier LH, Melton LJ, Van Peenen HJ, Cherry KJ, et al. Thoracic aortic aneurysms: A population-based study. Surgery 1982;92:1103-8.  Back to cited text no. 1
    
2.
Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation 2005;112:3802.  Back to cited text no. 2
    
3.
Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): New insights into an old disease. JAMA 2000;283:897-903.  Back to cited text no. 3
    
4.
Fadel A, Mazen S, Gibbson Michael F, Michel Leslie B, Peyton Marvin D. Right sided hemothorax: An uncommon manifestation of Type B aortic dissection (descending aortic dissection). Chest 2004;126:958S  Back to cited text no. 4
    
5.
Rogers AM, Hermann LK, Booher AM, Nienaber CA, Williams DM, Kazerooni EA, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: Results from the international registry of acute aortic dissection. Circulation 2011;123:2213-8.  Back to cited text no. 5
    
6.
Schoenfeld EM, Lemkin DL. Massive hemothorax from a Type-B aortic dissection. J Emerg Med 2012;43:e267-8.  Back to cited text no. 6
    
7.
Nienaber CA, von Kodolitsch Y, Nicolas V, Siglow V, Piepho A, Brockhoff C, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 1993;328:1-9.  Back to cited text no. 7
    
8.
Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, et al. Diagnosis and management of aortic dissection. Eur Heart J 2001;22:1642-81.  Back to cited text no. 8
    
9.
Harky A, Khalaf A, Francis C, Makar R, Balakrishnan A, Bashir M. Endovascular aortic repair versus open surgical repair for acute type B thoracic aortic dissection: A systematic review and meta-analysis. European J Vasc Endovasc Surg 2019;58 Suppl 2:E482-3.  Back to cited text no. 9
    
10.
Nienaber CA, Eagle KA. Aortic dissection: New frontiers in diagnosis and management: Part I: From etiology to diagnostic strategies. Circulation 2003;108:628-35.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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