Acute Onset of Chest Pain...

A 72-year-old man without significant past medical history presented to the emergency department with complaints of worsening lower extremity weakness and paraesthesias for two days. Associated symptoms included nausea, vomiting, diarrhoea and dysuria. He returned from Mexico one week prior to the presentation. The physical examination was remarkable for decreased muscle strength in both lower extremities. Initial data indicated a urinary tract infection for which intravenous (IV) levofloxacin was administered. A nerve conduction study was consistent with Guillain Barré Syndrome (GBS), but his neurologic abnormalities resolved rapidly. On the third hospital day, he developed acute onset chest discomfort and dyspnoea with hypoxia requiring supplemental oxygen. Physical examination revealed a new blowing, grade III/VI diastolic murmur which was loudest at onset and heard best in the third left intercostal space. Bibasilar crackles were auscultated. Discrepant blood pressures in the upper extremities (109/56 mm Hg from right arm and 154/ 66 mm Hg from left arm, respectively) were also noted. Additional data demonstrated an acute kidney injury with a creatinine of 3.0 mg/dL (baseline 1.1 mg/dL). Serial troponin measurements were unremarkable. 

A chest radiograph was done, transthoracic and transesophageal echocardiograms were performed. Aortic computed tomography angiogram (CTA) was done (Images 1-6). Cardiothoracic surgery was consulted.