Friday, 22 June 2007

Devil's Grip

A young adult male was admitted to another institution with severe upper chest pain that awoke him from sleep.

He had been previously well and had no serious underlying problems.

The pain was located in his upper chest and was severe (9/10) and made worse by lying flat. The pain was squeezing in nature, radiated to his back and was non-pleuritic. There was no associated breathlessness, cough, sputum or haemoptysis. The pain did not radiate to his neck, jaw or arms. He felt nauseated and sweaty but had not vomited.

He also complained of right upper quadrant abdominal pain. He had no other abdominal symptoms including the absence of diarrhoea, constipation, jaundice or malena.

On direct questioning, he denied doing any recent heavy lifting. He complained of no neck pain although he did mentioned that he had new onset 'katakori'. He did not have a stressful occupation.

Previous history included hyperlipidaemia, appendicetomy.

He was taking no regular medications.

He was a previous smoker having given up last year.

When he was initially examined there was a positive finding of fever which was low grade. The chest examination was unrevealing. Abdominal examination showed some right upper quadrant tenderness but no organomegally.

All bloods were normal except for a raised neutrophil count, low lymphocytes and rising CRP.

Initial differential diagnoses included;

  • Acute MI
  • Unstable angina
  • Variant angina
  • PE
  • Aortic dissection
  • Spontaneous pneumothoraces
  • Spontaneous rupture of oesophagus with surgical emphysema
  • Oesophageal spasm
  • Gastritis
  • Pericarditis

The serial ECGs revealed no pathological changes.

Chest radiograph showed no evidence of surgical emphysema, pneumothorax or enlargement of the superior mediastinum.

CT chest was performed and dissection was ruled out.

Echocardiogram of the heart revealed some mild left ventricle asynergy and abdominal scanning was normal.

In view of the abnormal echocardiogram result, the patient underwent coronary angiography which was normal.

Hence, despite the serious pains, no major abnormality could be found.

On further review on attending the same institution for review, the pain had mostly resolved, but he was left with some persistent abdominal discomfort and blood tests were still abnormal.

Examination was completely unremarkable.

The only major abnormality was the evidence of an inflammatory / infective episode. The mild LV asynergy made me consider a coxsackie infection. However, the CK and ECG were normal.

The diagnosis to be somewhat unusual and referred to as Bornholm Disease, but also known as Pleurodynia or Devil's Grip.

This is a viral infection caused by Coxsackie B virus (1-5 isotypes) affecting the diaphragmatic and intercostal muscles. It causes painful spasm and fever, and it can simulate the painful and potentially serious pathologies consider above. The condition occurs in summer months (hence, at this time) and adults are affected to a greater degree than children.

Having reviewed several texts, the general description is poorly reported with there being no definite bedside diagnostic criteria although a rising titre of anti-coxsackie antibody should be normally be checked . However, this is a diagnosis of inclusion when all other serious diagnoses have been ruled out.

Pleurodynia generally resolves with 6 days and treatment is with analgesics.

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