A 78-year-old man presents to the emergency department for a 2-day history of severe stabbing chest pain radiating to the back. His past medical history includes ST elevation myocardial infarction (STEMI) with percutaneous coronary intervention (PCI) to the proximal left anterior descending artery (LAD), insulin-dependent diabetes mellitus, hypertension, and paroxysmal atrial fibrillation. His wife at bedside mentions his most recent health issue was diarrhea from a month prior which self-resolved within 5 days. The patient is admitted to the hospital and has a series of diagnostic studies including serial troponins which are negative, transthoracic echocardiogram, and a nuclear cardiac stress test, which are all within normal limits. He also has bilateral lower extremity duplex ultrasonography, which is negative for deep vein thrombosis (DVT). Computed tomography angiography (CTA) of the chest and abdomen shows an intramural hematoma throughout the descending aorta with a small area of dissection noted at the distal descending aorta. There is aneurysmal dilatation of the origin of the superior mesenteric artery measuring up to 1.6 cm. There is also a small left pleural effusion with left lung base atelectasis.
Which of the following is the most likely underlying cause of the most likely diagnosis?
- A) Descending aortic dissection from atherosclerosi
- B) Mycotic aneurysm from a large vessel vasculitis
- C) Myocarditis
- D) Non-typhoidal salmonella (NTS) aortitis
- E) ST elevation myocardial infarction (STEMI)
Dr. Raj Dasgupta