Discussion: Chest pain is the most common complaint in the emergency department and frequently follows recognizable illness scripts; however, nonspecific chest pain in the setting of an unremarkable initial evaluation oftentimes does not initiate further investigation and can be overlooked as malingering. While cardiac and gastrointestinal causes of chest pain follow a specific pattern, it is imperative to consider vascular etiologies in the setting of concomitant chest pain and dysphagia. A Kommerell diverticulum is a proximal aneurysmal dilatation of an aberrant subclavian artery and often accompanied by other congenital abnormalities of the aortic arch. The specific combination of a Kommerell diverticulum with right-sided aortic arch and aberrant left subclavian artery is exceptionally rare. It is usually asymptomatic and found on incidental imaging; however, presentations may include chest pain, dysphagia, syncope, and reactive airway disease. This case highlights the diagnostic challenge of identifying vascular anomalies as a cause of chest pain in an otherwise young, healthy adult while concomitantly challenging our implicit bias in an individual whose behaviors align with malingering.
patient also noted a history of unwitnessed syncopal episodes, with a recent episode precipitated during a bowel movement. On chart review, the patient had a pervasive history over the prior decade of routine emergency department visits in multiple states for nonspecific chest pain for which basic evaluation was consistently unrevealing. Pertinent findings his on physical examination included distractible pain to light palpation of the anterior chest wall and diffusely over the abdomen and mild expiratory wheezes auscultated in the upper left lung field. Labs were grossly unremarkable. A chest x-ray revealed abnormal thickening of the tracheo-esophageal interface, concerning for a posterior mediastinal abnormality. A CT of the chest with contrast showed a right-sided aortic arch with aberrant left subclavian artery and associated 2.4 cm Kommerell diverticulum. A CT esophagram further delineated a bulbous enlargement of the proximal subclavian artery posterior to the esophagus with evidence of compression by the left subclavian artery on the adjacent esophagus causing displacement anteriorly. Patient was referred for outpatient evaluation with Vascular Surgery but ultimately lost to follow up.
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