Endgames Case Review

An often forgotten cause of chest pain

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1846 (Published 08 April 2016) Cite this as: BMJ 2016;353:i1846
  1. Sanjin Bajgoric, foundation year 2 doctor1,
  2. William Boyd-Carson, foundation year 1 doctor2,
  3. Christopher Day, consultant vascular and interventional radiologist3,
  4. Sriram Rajagopalan, consultant vascular surgeon4
  1. 1Emergency Department, Royal Stoke University Hospital, Stoke on Trent ST4 6QG, UK
  2. 2Department of Medicine, Royal Stoke University Hospital
  3. 3Department of Radiology, Royal Stoke University Hospital
  4. 4Department of Vascular Surgery, Royal Stoke University Hospital
  1. Correspondence to: S Bajgoric sanjinbajgoric{at}gmail.com

A 66 year old white woman presented to the emergency department of a district general hospital with shortness of breath and chest pain, which radiated to her back. She had previously received antibiotics from her general practitioner for a presumed chest infection. Comorbidities included drug controlled hypertension. On examination she was tachypnoeic and hypertensive with a blood pressure of 170/90 mm Hg. No disparity in blood pressure was seen between her arms. Because clinical signs and plain chest radiography were suggestive of a left sided basal pneumonia with associated parapneumonic effusion (fig 1), she received intravenous antibiotics.

Fig 1 Left pleural effusion on computed tomography (white asterisk)

Poor clinical response prompted further imaging to rule out pulmonary embolism. This identified a large distal thoracic penetrating aortic ulcer (PAU) at the level T11-12 with associated intramural haematoma (IMH) and a left sided pleural effusion (fig 2). She was transferred urgently to a regional tertiary vascular centre for further management and later discharged with appropriate follow-up.

Fig 2 Axial computed tomography at different levels of the thoracic aorta (A) before and (B) after intravenous administration of iodinated contrast. (C) Sagittal multiplanar reformatted image (MPR) after iodinated contrast administration. Intramural haematoma is seen as a crescent of high attenuation within the wall of the aorta best identified before contrast administration (A; white arrows) but also seen on the MPR (C; white arrows). A large penetrating ulcer is seen in the distal descending thoracic aorta (B and C; black asterisk). A large pleural effusion is seen on the left side (A and B; white asterisk)


  1. To what group of conditions do penetrating aortic ulcers and intramural haematomas belong?

  2. What are the risk factors for these conditions?

  3. What is the most common presenting problem?

  4. What is the most appropriate diagnostic investigation?

  5. How are …

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