The myocardial infarction
Aortic dissection may extend retrogradely to involve the coronary sinus of the right coronary artery. Unfortunately, in this patient’s case the right coronary artery became occluded as the dissection passed into the origin. In normal individuals the right coronary artery supplies the anterior inferior aspect of the myocardium, and this is evident as an anterior myocardial infarct on an ECG.
The ischemic left leg
The two channels within the aorta have extended throughout the length of the aorta into the right iliac system and to the level of the right femoral artery. Although blood flows through these structures it often causes reduced blood flow. Hence the reduced blood flow into the left lower limb renders it ischemic.
The patient became acidotic.
All cells in the body produce acid, which is excreted in the urine or converted into water with the production of carbon dioxide, which is removed with ventilation. Unfortunately, when organs become extremely ischemic they release significant amounts of hydrogen ions. Typically, this occurs when the gut becomes ischemic. With the pattern of dissection, (1) the celiac trunk, superior mesenteric artery, and inferior mesenteric artery can be effectively removed from the circulation or (2) the blood flow within these vessels can be significantly impeded, rendering the gut ischemic and hence accounting for the relatively high hydrogen ion levels.
Similarly the dissection can impair blood flow to the kidneys, which decreases their ability to function.
The patient underwent emergency surgery and survived. Interestingly, the height of the patient and the previous lens surgery would suggest a diagnosis of Marfan syndrome, and a series of blood tests and review of the family history revealed this was so.
A 35-year-old male patient presented to his family practitioner because of recent weight loss (14 lb over the previous 2 months). He also complained of a cough with streaks of blood in the sputum (hemoptysis) and left-sided chest pain. Recently, he noticed significant sweating, especially at night, which necessitated changing his sheets.
On examination the patient had a low-grade temperature and was tachypneic (breathing fast). There was reduced expansion of the left side of the chest. When the chest was percussed it was noted that the anterior aspect of the left chest was dull, compared to the resonant percussion note of the remainder of the chest. Auscultation (listening with a stethoscope) revealed decreased breath sounds, which were hoarse in nature (bronchial breathing).
A diagnosis of chest infection was made.
Chest infection is a common disease. In most patients the infection affects the large airways and bronchi. If the infection continues, exudates and transudates are produced, filling the alveoli and the secondary pulmonary lobules. The diffuse patchy nature of this type of infection is termed bronchial pneumonia.
Given the patient’s specific clinical findings, bronchial pneumonia was unlikely.
From the clinical findings it was clear that the patient was likely to have a pneumonia confined to a lobe. Because there are only two lobes in the left lung, the likely diagnosis was a left upper lobe pneumonia.
A chest radiograph was obtained (eFig. 3.121). The posteroanterior view of the chest demonstrated an area of veil-like opacification throughout the whole of the left lung.
Knowing the position of the oblique fissure, any consolidation within the left upper lobe will produce this veil-like shadowing. Lateral radiographs are usually not necessary but would demonstrate opacification anteriorly and superiorly that ends abruptly at the oblique fissure.
Upper lobe pneumonias are unusual because most patients develop gravity-dependent infection. Certain infections, however, are typical within the middle and upper lobes, commonly, tuberculosis (TB) and histoplasmosis.
A review of the patient’s history suggested a serious and chronic illness and the patient was admitted to hospital.