HYPOTENSION WITH ST ELEVATIONS.NOT A STEMI OR EVEN THE HEART

ABSTRACT

CASE Mr. S is a 60 yo man with DM, HTN and HLD who presents to the urgent care (UC) clinic complaining of sore throat and phlegm in the throat. He is noted to have normal vital signs except for a BP of 75/47. Exam showed slight erythema of the oropharynx, normal cardiac and pulmonary exams. Initial treatment of fluid resuscitation is started for his presumed sepsis, thought secondary to presumed COVID-19 as this occurred during the Omicron surge. An EKG was performed showing anteriolateral ST elevations. The patient was transported emergently to the hospital. An immediate cardiac catheterization was performed which showed mild coronary artery disease, but no obstruction. At this time, COVID-19 PCR test returns negative. The patient is transfered to the MICU for further evaluation and treatment for hypotension/septic shock. At this time, a chest x-ray demonstrated subcutaneous gas in the soft tissues of the neck. CT imaging showed subcutaneous gas extending from the neck to the mediastinum. Patient was taken to the operating room and found to have significant pus in the neck and mediastinum. He was diagnosed with necrotizing mediastinitis requiring multiple surgical wash-outs and prolonged SICU stay. The source was a suspected dental extraction. His ST elevations were presumed to be secondary to a pericarditis effect from the mediasinitis. IMPACT/DISCUSSION: Overall, this case presents necrotizing mediastinitis which is a very unusual and rare presentation, however, it is a surgical emergency so internists need to be aware of this disease and its presentation. Additionally, this case identifies four important points. The first is to make a broad differential, specifically for hypotension. In the setting of a sore throat during the Omicron surge, it was easy to assume this was COVID-19 but thinking of other etiologies led to the EKG being performed. The second is the importance of the physical exam. After the CXR was seen, the patient was examined and noted to have subcutaneous gas which could have been noted at the initial UC visit but that piece of the exam was not performed as the focus was on the hypotension. Third, there is a differential for etiologies of ST elevation on EKG which include STEMI, pericarditis, early repolarization, etc. that should be considered while preparing for treatment of STEMI. Lastly, taking a extensive history, to include dental work, is important as there may be systemic effects of these experiences/treatments. CONCLUSION: -Make a broad differential for atypical patient presentations and physical exam findings -Review EKGs carefully and make a differential for those findings -Necrotizing mediastinitis is a rare presentation but life threatening and needs immediate surgical attention.