American College of Physicians: Internal Medicine — Doctors for Adults ®


Eponymous chest pain

From the November ACP Hospitalist, copyright © 2013 by the American College of Physicians

By Gaby Frank, MD, FACP, and James S. Newman, MD, FACP

It's a chilly November morning, and the cold air makes your lungs ache. You're running late as usual, and your service pager just went off 3 times, each with the admission of a young woman with chest pain. You hope you're being paged about the same patient 33 times. You are really not looking forward to the day, since you have to round with an annoying hospital medicine fellow who is a major history buff.

You figure you might as well head down to the ED on the way in and size up the situation. A few minutes later, the fellow huffs and puffs his way over. His sweaty shirt is untucked, and he smells like stale cigarettes. You walk into the emergency critical area, and of course there are 33 young women clutching their chests. They are each in their 20s with recurrent reproducible sternal pain. Their troponins are all normal, as are their EKGs. You wonder why these patients need admission when this is obviously musculoskeletal pain and all they need are nonsteroidals.

Photo from Thinkstock.

Photo from Thinkstock.

The fellow looks at you, slipping into pontificating mode. He explains that the diagnosis you have made is “Tietze syndrome.” You joke that it has nothing to do with African sleeping sickness and flies. He ignores you and begins to explain....

In 1921, Dr. Alexander Tietze described 33 patients with painful, self-limited but sometimes recurrent nonsuppurative swelling of the costochondral or sternoclavicular joints. All 33 patients were women. Dr. Tietze emphasized that none of the patients had any evidence of tuberculosis or syphilis and attributed the findings to a nutritional disorder of the cartilage leading to calcium deposition in the area and causing associated inflammation.

You thank the fellow and actually feel vaguely enlightened, until the pager beeps again. You sigh. It's the VIP floor. You head toward the elevator, but in a last-minute uncharitable moment you head to the stairs. The fellow trails you up all seven flights. You know you are entering the special ward by the carpeting, fine furniture and golden faucets in the sinks. Even the hand sanitizer is a fine vintage.

Your patient is a major donor with an eating disorder. He is complaining of severe retrosternal chest pain, and the chest X-ray shows free air. You look at the fellow. You know its Boerhaave's syndrome. You grit your teeth.

The fellow grimaces, still catching his breath. Herman Boerhaave, he explains, was a Dutch physician, philosopher, chemist and physicist. He trained at the University of Leiden, famous for Van Leuwenhoek and the microscope, and many years later for an abnormal version of factor V. Dr. Boerhaave was a pioneer of the modern academic hospital as he was one of the first teachers to emphasize the relationship between symptoms and lesions. In 1724, Dr. Boerhaave described the history of a Dutch baron who suffered from recurrent epigastric pain that he would relieve by forced emesis. The day the baron developed his esophageal tear, he had partaken of a gluttonous feast and subsequently treated himself with Ipecacuanha.

The pager beeps again. You consider defenestration. It's the ED with a patient with rhythmic episodes of chest pain and a normal EKG. You charge down the stairs, only to find the woman writhing in pain. This looks pretty serious. But if it is cardiac in the face of normal studies, perhaps it is Prinzmetal's angina.

The fellow finally arrives, looking pretty pale, but this doesn't keep him from telling you that Myron Prinzmetal was born in Buffalo, N.Y., and received his medical degree at age 25 from the University of California at San Francisco. Dr. Prinzmetal published 165 articles and two books and was a co-developer of high-speed cine-electrocardiography. In 1959, Dr. Prinzmetal published a preliminary report describing 32 cases of a variant form of angina, occurring at rest in patients who had normal EKGs in the absence of pain and whose examinations and stress tests were normal. Most of his patients had symptoms that had a circadian pattern, with attacks consisting of rhythmic bouts of pain occurring usually at night. Dr. Prinzmetal suggested that coronary artery spasm might be the cause (as was subsequently confirmed).

Just when you think the day's been busy enough, you get a call about a patient who had transferred out of the critical care unit last week post-MI. He now has chest pain, and when you examine him you hear a distinct friction rub. Here it comes, you think. The ashen-faced fellow wheezes that William Dressler was born and educated in Vienna and worked as a cardiologist at the Maimonides Cardiac Institute in Brooklyn, N.Y. Between 1955 and 1956, he published several articles describing a post-myocardial infarction syndrome involving a combination of pericarditis, pleurisy and pneumonitis, with or without fever and leukocytosis.

You think you might actually be enjoying the historic correlates to your patients when you turn to face the fellow and find him lying on the floor. He is diaphoretic and grabbing his chest. You call a code. They rush him to the ED, where his EKG shows an ST-elevation MI. You feel so guilty for maliciously running him up and down the stairs.

As they rush him to the cath lab, he grabs your arm. You expect some heartfelt comment; you want to apologize. But he looks you square in the eyes, and as they wheel him off you hear him say to the nurse, “Did you know the first cardiac catheter was placed by Werner Forssmann in 1929?”

Dr. Frank is associate chief of hospital medicine at Denver Health and Hospital Authority and assistant professor of medicine at the University of Colorado School of Medicine in Denver. Dr. Newman is a hospitalist at the Mayo Clinic in Rochester, Minn., and the editorial advisor and humor columnist for ACP Hospitalist.


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