An unusual case of coronary mimicry

Abstract

DESCRIPTIONA 64-year-old man with no significant medical history was referred to the emergency department (ED) due to acute chest pain, suggestive of an acute coronary syndrome. Acetylsalicylic acid 500 mg and glyceryl trinitrate spray had been administered in the ambulance, and when the patient arrived in the ED the chest pain had subsided significantly. At presentation, he was markedly hypertensive (240/ 110 mm Hg). A first ECG ( figure 1A) demonstrated left ventricular hypertrophy, but was otherwise unremarkable. However, since troponin T levels were slightly elevated (32 ng/L, upper reference limit 14 ng/L), intravenous nitroglycerine was started and 5000IE of heparin was administered.Twenty-eight minutes later his condition deteriorated: the chest pain increased and he developed significant abdominal pain and diaphoresis. A second ECG ( figure 1B) showed an episode of junctional rhythm (51 bpm), whereas CT scan demonstrated an active abdominal bleeding originating from the right adrenal region extending cranially to the diaphragm ( figure 2A, B).Conservative treatment (thrombocyte transfusion and blood pressure control) was initiated in the intensive care unit, where he made a full recovery. During follow-up, metanephrine, normethanephrine and 3-methoxytyramine levels were not elevated, and a fluorodexyglucose (FDG) positron-emission tomography CT scan did not demonstrate an increased FDG uptake in the renal/adrenal region; the bleeding was presumed to be related to severe essential hypertension.