A 19 Year-Old Man With Chest Pain

Abstract

A 19-year-old man with no past medical history presented to the ER with a sore throat, cough, and pleuritic chest pain. The patient had been well until 1 month before admission, when he developed a sore throat and felt ill. He presented to the emergency department twice for these symptoms. On the first visit, the patient had a positive rapid strep test. He was diagnosed with strep throat and treated with penicillin IM. However, his sore throat persisted. Five days before admission, the patient developed a non-productive cough. One day prior to admission he developed severe right sided chest pain that was throbbing, pleuritic, and radiated to his right shoulder. The pain, which was initially relieved by sitting forward and with Ibuprofen, continued to worsen, prompting the patient's mother to bring him back to be re-evaluated.Upon presentation, the patient denied shortness of breath, fevers, or chills. He had no personal history of prenatal or childhood disease, and denied family history of early heart disease, lung disease, cancer or bleeding disorders. He denied tobacco, alcohol, or illicit drug use. He reported being heterosexual with 4-5 lifetime sexual partners, and one new partner in the prior two months.On examination, the patient was a well nourished, well developed, young African American man in moderate distress. The blood pressure was 117/57, heart rate 66, respiratory rate 16, oxygen saturation 98% on 2 L nasal cannula and temperature 37.5ºC. The physical exam was remarkable only for slight pharyngeal erythema and enlarged, non-purulent tonsils. His heart was without murmurs, rubs, or gallops. His lungs were clear to auscultation bilaterally. Initial labwork was unremarkable, with a normal white blood cell count. A chest radiograph revealed findings in the right lower lobe concerning for subsegmental atelectasis versus consolidation. Electrocardiogram demonstrated an incomplete right bundle branch block. A thoracic CT demonstrated a large right lower lobe pulmonary embolism with an associated area of pulmonary infarction.Given the finding of the patient's pulmonary embolism, our top three differential diagnoses were a primary underlying hypercoagulable state, an infection predisposing the patient to a hypercoaguable state, or an underlying malignancy. The patient was admitted to the hospital, blood work was drawn, and he was started on Warfarin with an Enoxaparin bridge. During his work up, the patient was found to have elevated antistreptolysin O titers, consistent with a prior streptococcus infection. Blood cultures were negative. In addition, HIV, HSV, gonorrhea, chlamydia, group A strep, and H1N1 PCR were all negative. CT of the abdomen and pelvis and testicular ultrasound were normal, without any signs of malignancy. A rheumatologic workup, including an anti-nuclear antibody and anti-neutrophil cytoplasmic antibody were negative. A hypercoagulable work up was sent prior to initiation of anticoagulation therapy. Protein C, protein S, factor V leiden, antithrombin III, and anticardiolipin antibodie...