case report Wien Klin Wochenschr DOI 10.1007/s00508-015-0811-x
Needle fragment embolism into the right ventricle: a rare cause of chest pain case report and literature review Barbara Anna Danek · Petr Kuchynka · Tomas Palecek · Vladimir Cerny · Karel Hlavacek · Lukas Lambert · Eduard Nemecek · Jana Podzimkova · Ales Linhart
Received: 4 March 2015 / Accepted: 14 May 2015 © Springer-Verlag Wien 2015
Summary Chest pain in young adults is usually selflimited and of benign etiology. However, rare causes of chest pain must be considered in patients for whom initial diagnostic tests are negative, particularly if unusual risk factors are identified. The authors present a rare case describing a 27-year-old male intravenous drug user who developed transient chest pain most likely secondary to pericardial irritation caused by a needle fragment that embolized from a peripheral vein to his right ventricle. The current literature on intracardiac needles and similar foreign bodies is discussed, providing insight to the epidemiology, complications, and treatment of such patients. Keywords Chest pain · Drug user · Needle embolism · Right ventricle
Introduction Young adults who present with chest pain most frequently have gastrointestinal disease, pulmonary disease, or musculoskeletal disorders underlying their symptoms. However, less common causes of chest pain should be considered when initial diagnostic tests are negative, particularly if unusual risk factors are present. We describe an interesting case of a patient who developed exertional chest pain in the setting of a history of intravenous drug use. Intravenous drug users are at risk for a range of complications associated with bloodstream access, including infectious endocarditis, lung infections, thrombotic complications at the injection site or distally, and rarely, embolization of foreign bodies [1].
Case report P. Kuchynka, MD, PhD () · B. A. Danek · T. Palecek, MD, PhD · E. Nemecek, MD · J. Podzimkova, MD · A. Linhart, MD, PhD 2nd Department of Medicine—Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague 2, Czech Republic e-mail: [email protected] T. Palecek, MD, PhD · P. Kuchynka, MD, PhD International Clinical Research Center, St. Anne’s University Hospital in Brno, Brno, Czech Republic V. Cerny, MD · L. Lambert, MD, PhD Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic K. Hlavacek, MD, PhD Department of Cardiology Bulovka, Prague, Czech Republic
13
A 27-year-old male smoker with a history of intravenous (IV) drug use, hepatitis C, and bronchial asthma presented with recurring stabbing chest pain on exertion. The patient did not have a recent history of trauma, nor did he recall any recent respiratory or gastrointestinal infections. The patient reported last using IV drugs 2 years prior to the current presentation. Upon admission he was afebrile and hemodynamically stable, with blood pressure of 130/80 mmHg and heart rate 72 beats per minute. Physical examination revealed no abnormalities. An electrocardiogram (ECG) showed sinus rhythm with normal QRS duration, normal PQ and QT intervals, and ST-T changes suggestive only of early repolarization (Fig. 1). Transthoracic echocardiographic examination (TTE) demonstrated normal size and normal systolic as well as diastolic function of both ventricles. The estimated pulmonary artery systolic pressure was within the normal range, and there was no valvular disease or pericardial effusion. A posterior-anterior chest radiograph
Needle fragment embolism into the right ventricle: a rare cause of chest pain case report and literature review
1
case report Fig. 1 An electrocardiogram performed on initial evaluation of the patient. No significant pathological changes apart from signs of early repolarization were identified
Fig. 2 Left ventriculography demonstrating the presence of a thin, radio-opaque object (marked with arrow) located within the apex of the right ventricle
Fig. 3 Chest computed tomography showing a metallic object (marked with arrow), embedded within the myocardium of the right ventricle, extending into the apical part of the left ventricle
showed clear lung fields and a slender cardiac silhouette, with no obvious abnormalities. The following laboratory examinations were within normal limits: erythrocyte sedimentation rate (ESR 4 mm/h), C-reactive protein (
Needle fragment embolism into the right ventricle: a rare cause of chest pain case report and literature review Barbara Anna Danek · Petr Kuchynka · Tomas Palecek · Vladimir Cerny · Karel Hlavacek · Lukas Lambert · Eduard Nemecek · Jana Podzimkova · Ales Linhart
Received: 4 March 2015 / Accepted: 14 May 2015 © Springer-Verlag Wien 2015
Summary Chest pain in young adults is usually selflimited and of benign etiology. However, rare causes of chest pain must be considered in patients for whom initial diagnostic tests are negative, particularly if unusual risk factors are identified. The authors present a rare case describing a 27-year-old male intravenous drug user who developed transient chest pain most likely secondary to pericardial irritation caused by a needle fragment that embolized from a peripheral vein to his right ventricle. The current literature on intracardiac needles and similar foreign bodies is discussed, providing insight to the epidemiology, complications, and treatment of such patients. Keywords Chest pain · Drug user · Needle embolism · Right ventricle
Introduction Young adults who present with chest pain most frequently have gastrointestinal disease, pulmonary disease, or musculoskeletal disorders underlying their symptoms. However, less common causes of chest pain should be considered when initial diagnostic tests are negative, particularly if unusual risk factors are present. We describe an interesting case of a patient who developed exertional chest pain in the setting of a history of intravenous drug use. Intravenous drug users are at risk for a range of complications associated with bloodstream access, including infectious endocarditis, lung infections, thrombotic complications at the injection site or distally, and rarely, embolization of foreign bodies [1].
Case report P. Kuchynka, MD, PhD () · B. A. Danek · T. Palecek, MD, PhD · E. Nemecek, MD · J. Podzimkova, MD · A. Linhart, MD, PhD 2nd Department of Medicine—Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague 2, Czech Republic e-mail: [email protected] T. Palecek, MD, PhD · P. Kuchynka, MD, PhD International Clinical Research Center, St. Anne’s University Hospital in Brno, Brno, Czech Republic V. Cerny, MD · L. Lambert, MD, PhD Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic K. Hlavacek, MD, PhD Department of Cardiology Bulovka, Prague, Czech Republic
13
A 27-year-old male smoker with a history of intravenous (IV) drug use, hepatitis C, and bronchial asthma presented with recurring stabbing chest pain on exertion. The patient did not have a recent history of trauma, nor did he recall any recent respiratory or gastrointestinal infections. The patient reported last using IV drugs 2 years prior to the current presentation. Upon admission he was afebrile and hemodynamically stable, with blood pressure of 130/80 mmHg and heart rate 72 beats per minute. Physical examination revealed no abnormalities. An electrocardiogram (ECG) showed sinus rhythm with normal QRS duration, normal PQ and QT intervals, and ST-T changes suggestive only of early repolarization (Fig. 1). Transthoracic echocardiographic examination (TTE) demonstrated normal size and normal systolic as well as diastolic function of both ventricles. The estimated pulmonary artery systolic pressure was within the normal range, and there was no valvular disease or pericardial effusion. A posterior-anterior chest radiograph
Needle fragment embolism into the right ventricle: a rare cause of chest pain case report and literature review
1
case report Fig. 1 An electrocardiogram performed on initial evaluation of the patient. No significant pathological changes apart from signs of early repolarization were identified
Fig. 2 Left ventriculography demonstrating the presence of a thin, radio-opaque object (marked with arrow) located within the apex of the right ventricle
Fig. 3 Chest computed tomography showing a metallic object (marked with arrow), embedded within the myocardium of the right ventricle, extending into the apical part of the left ventricle
showed clear lung fields and a slender cardiac silhouette, with no obvious abnormalities. The following laboratory examinations were within normal limits: erythrocyte sedimentation rate (ESR 4 mm/h), C-reactive protein (
