Enigmatic patient Causes and Symptoms | click, click, click
Enigmatic patient: From the upper body of a healthy 19-year-old sounds suddenly clicking sounds. The next day he feels pain in his chest. Is something wrong with the heart? The doctors find another explanation.
The young man lies in bed when he hears the noise for the first time. From his chest a click sounds. It seems to him that it appears in the rhythm of his pulse. Does he have a heart problem? The concern worries the 19-year-old only briefly, because otherwise he has no physical ailments. He is currently undergoing training at a Swiss military school. The thing with the noise, which occurs only in a specific lying position, he retains for once.
The following day, during a march with luggage, he feels stabbing pains in his chest and back. They mostly occur when he is running or jumping. Because he has often had back pain, he first assumes that they simply plague him again.
When he finally tells his doctor about the symptoms, he sends him to the Cantonal Hospital of Baden, so that the cause of the click is found. Once there, the 19-year-old is examined immediately in the emergency room.
Tall and skinny
The medical team around Jürg Hans Beer describes in the journal “BMJ Case Reports” a tall, very thin man who seems to be doing well overall: his vital signs are normal, when listening to the lungs, nothing unusual is noticeable.
The man has no breathing difficulties, no cough, no signs of injury. In his family, there are no illnesses that indicate a possible cause of his complaints.
The most probable from the doctors’ point of view is that a heart valve causes the noise. The patient receives an appointment for a heart ultrasound, which takes place two days later, and can leave the clinic once again.
The flaps are not
The click is heard at the ultrasound appointment, the doctor takes it with his smartphone. However, the investigation reveals a healthy heart whose valves are definitely not responsible for the noise. Using computed tomography (CT), the physicians now examine the heart and surrounding tissue.
Here is the cause of the noise: On the left side there is air in the space between the lung and pleura, the so-called pleural cavity. The lung can no longer expand accordingly when inhaled. Pneumothorax doctors call the phenomenon.
For the man, the case is unfortunately not yet completed. For several times he develops a pneumothorax again. After all less invasive methods fail to show lasting success, the doctors remove a small portion of the left lung – and fix the problem permanently.
In their case report, Beer and colleagues write that the so-called Hamman sign, a pulse-synchronous noise from the chest, was first described in the 19th century. A flattened pneumothorax on the left side is therefore the most common cause of the noise, which can also be a crunching or bubbling. It is believed that it arises when the expanding and contracting heart moves the accumulated air in the chest.
Nevertheless, it is probably a fairly rare symptom of a spontaneous pneumothorax, as it had the 19-year-old. In the past 20 years, according to the doctors, only three case reports were published in which the two came together. And as in the current Swiss case, the physicians did not immediately have the right diagnosis in the other cases.