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A Case of Atypical Retrosternal Chest Pain

      To the Editor:
      In October 2011, a previously healthy 50-year-old man presented to the emergency department with a 1-hour history of progressive, retrosternal chest pain radiating up to his throat that began suddenly at rest. The patient was hospitalized for further examinations. At presentation, the pain had intensified to 7 on a scale of 10. There was no associated cough or shortness of breath, sweating, nausea, hematemesis, or melena. Sublingual nitroglycerin did not improve the symptoms, whereas a slow intravenous infusion of tramadol hydrochloride relieved pain. Before this episode, he used to perform 6 hours of moderate aerobic cardiovascular exercise per week and followed a healthy diet.
      Clinical examination on admission revealed no abnormal findings. His troponin T level was 0.003 ng/mL (highly sensitive assay, normal <0.014), creatine kinase level was 67 IU/L (normal 30-170), and creatine kinase MB level was 1.91 ng/mL (normal <7.00).
      He had normal results on electrocardiography at rest; however, he underwent an exercise treadmill test to evaluate atypical angina, which showed negative results. A chest computed tomography scan ordered to rule out a dissecting aortic aneurysm instead revealed an eccentric thickening of the esophageal wall, maximum dimensions of 4 cm in length and 3 cm in width, with compression of the lumen and in some sections complete luminal occlusion (Figure 1). Careful endoscopy showed a submucosal lesion of the proximal esophagus covered by normal mucosa occluding the visceral lumen but allowing the progression of a pediatric endoscopic tube. Endoscopic ultrasonography revealed a hypoechoic submucosal lesion 3 cm in diameter (Figure 2). No lymphadenopathy was noted.
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      Figure 1Computed tomography scan shows extensive eccentric thickening of the thoracic esophagus wall up to a maximum of more than 4 cm. The esophageal lumen (A, arrow) and completely obliterated esophageal lumen (B).
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      Figure 2Endoscopic ultrasonography with a linear echo-endoscope shows a large hypoechoic intramural lesion (arrows).
      Benign esophageal tumors represent less than 1% of esophageal neoplasms typically occurring in patients aged 20 to 50 years.
      • Mutrie C.J.
      • Donahue D.M.
      • Wain J.C.
      • et al.
      Esophageal leiomyoma: a 40-year experience.
      Leiomyomas are the most common benign esophageal tumors and account for more than 70% of all benign tumors.
      • Mutrie C.J.
      • Donahue D.M.
      • Wain J.C.
      • et al.
      Esophageal leiomyoma: a 40-year experience.
      The majority are usually located in the distal two thirds of the esophagus.
      • Punpale A.
      • Rangole A.
      • Bhambhani N.
      • et al.
      Leiomyoma of esophagus.
      Typically, the symptoms are dysphagia and epigastric pain, although they are not specific for the disease. The differential diagnosis always should include esophageal cancer.
      • Punpale A.
      • Rangole A.
      • Bhambhani N.
      • et al.
      Leiomyoma of esophagus.
      In relation to the usual clinical manifestation of esophageal leiomyomas, the case described is rare and its presentation can mimic cardiovascular diseases. Surgical excision is recommended for symptomatic leiomyomas and those greater than 5 cm. Our patient preferred to be followed with computed tomography scans every year rather than undergo operation.

      References

        • Mutrie C.J.
        • Donahue D.M.
        • Wain J.C.
        • et al.
        Esophageal leiomyoma: a 40-year experience.
        Ann Thorac Surg. 2005; 79: 1122-1125
        • Punpale A.
        • Rangole A.
        • Bhambhani N.
        • et al.
        Leiomyoma of esophagus.
        Ann Thorac Cardiovasc Surg. 2007; 13: 78-81