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Case report
peer-reviewed

How an Elevated Creatinine Level Can Deter the Diagnosis of Acute Aortic Dissection



Abstract

Acute aortic dissection (AAD) classically manifests with sudden, severe chest pain radiating to the back or abdomen, often described as ripping or tearing sensation. Considering its abrupt onset, the diagnosis requires a high index of suspicion prompting immediate imaging using computed tomography (CT) with contrast. However, the use of contrast is a relative contraindication in the patients with renal compromise and acute care physicians are often deterred from contrast use in these patients. Herein, we present an unusual case of hematuria as the presenting symptom of a developing the Stanford type-A AAD.

A 65-year-old female presented with sudden, severe chest pain radiating to her lower back. She reported that her urine color was 'pink' on the previous day and was becoming more 'red-colored' as the day progressed. The next morning, she began feeling a 10/10 crushing-type chest pain that was relieved when she lay on her left side and was associated with nausea, vomiting, and diaphoresis. The urine analysis revealed gross hematuria. The laboratory findings revealed a creatinine of 1.3. Due to her elevated creatine levels and possible acute kidney injury, a computed tomography (CT) without contrast was performed initially, which did not reveal an AAD. However, the index of suspicion was still high for the AAD, after prompt discussions about the risk of using contrast and contrast nephropathy versus the risks of potential complications, if AAD was missed. Further evaluation with CT of the chest and abdomen, with contrast, was obtained with the patients' consent, which revealed a Stanford type-A AAD starting proximally from the aortic arch and extending to the common iliac.

In conclusion, the clinical presentations of AAD are more heterogeneous. Hematuria in the presence of high index of suspicion and symptoms of AAD could indicate the extension of the involvement of the renal arteries. Prompt CT with contrast may be indicated despite relative contraindications from the laboratory findings.



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Case report
peer-reviewed

How an Elevated Creatinine Level Can Deter the Diagnosis of Acute Aortic Dissection


Author Information

Mohamed A. Mohamed Corresponding Author

College of Human Medicine, Michigan State University

Kewan A. Hamid

Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center, Michigan State University College of Human Medicine


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


Case report
peer-reviewed

How an Elevated Creatinine Level Can Deter the Diagnosis of Acute Aortic Dissection


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Case report
peer-reviewed

How an Elevated Creatinine Level Can Deter the Diagnosis of Acute Aortic Dissection

  • Author Information
    Mohamed A. Mohamed Corresponding Author

    College of Human Medicine, Michigan State University

    Kewan A. Hamid

    Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center, Michigan State University College of Human Medicine


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

    Acknowledgements


    Article Information

    Published: January 12, 2018

    DOI

    10.7759/cureus.2057

    Cite this article as:

    Mohamed M A, Hamid K A (January 12, 2018) How an Elevated Creatinine Level Can Deter the Diagnosis of Acute Aortic Dissection. Cureus 10(1): e2057. doi:10.7759/cureus.2057

    Publication history

    Received by Cureus: November 29, 2017
    Peer review began: December 06, 2017
    Peer review concluded: January 08, 2018
    Published: January 12, 2018

    Copyright

    © Copyright 2018
    Mohamed et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Acute aortic dissection (AAD) classically manifests with sudden, severe chest pain radiating to the back or abdomen, often described as ripping or tearing sensation. Considering its abrupt onset, the diagnosis requires a high index of suspicion prompting immediate imaging using computed tomography (CT) with contrast. However, the use of contrast is a relative contraindication in the patients with renal compromise and acute care physicians are often deterred from contrast use in these patients. Herein, we present an unusual case of hematuria as the presenting symptom of a developing the Stanford type-A AAD.

A 65-year-old female presented with sudden, severe chest pain radiating to her lower back. She reported that her urine color was 'pink' on the previous day and was becoming more 'red-colored' as the day progressed. The next morning, she began feeling a 10/10 crushing-type chest pain that was relieved when she lay on her left side and was associated with nausea, vomiting, and diaphoresis. The urine analysis revealed gross hematuria. The laboratory findings revealed a creatinine of 1.3. Due to her elevated creatine levels and possible acute kidney injury, a computed tomography (CT) without contrast was performed initially, which did not reveal an AAD. However, the index of suspicion was still high for the AAD, after prompt discussions about the risk of using contrast and contrast nephropathy versus the risks of potential complications, if AAD was missed. Further evaluation with CT of the chest and abdomen, with contrast, was obtained with the patients' consent, which revealed a Stanford type-A AAD starting proximally from the aortic arch and extending to the common iliac.

In conclusion, the clinical presentations of AAD are more heterogeneous. Hematuria in the presence of high index of suspicion and symptoms of AAD could indicate the extension of the involvement of the renal arteries. Prompt CT with contrast may be indicated despite relative contraindications from the laboratory findings.



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Create a free account to continue reading this article.

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Mohamed A. Mohamed

College of Human Medicine, Michigan State University

For correspondence:
mohame57@msu.edu

Kewan A. Hamid

Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center, Michigan State University College of Human Medicine

Mohamed A. Mohamed

College of Human Medicine, Michigan State University

For correspondence:
mohame57@msu.edu

Kewan A. Hamid

Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center, Michigan State University College of Human Medicine