A 57-year-old African American woman presented with a 1-day history of atypical substernal chest pain which was intermittent, non-pleuritic, and non-exertional. She also reported a 3-month history of dysphagia (predominantly for solids) which she described as 'food stuck in my throat'. In addition, our patient reported a 20-pound weight loss over 3 months. She had occasional nausea and heartburn, however she denied any vomiting, odynophagia, abdominal pain, or regurgitation of food. Her medical history was significant only for gastroesophageal reflux disease. She denied any tobacco, alcohol, or drug use. She was not on any prescribed medications.
Physical examination revealed cachexia but was otherwise unremarkable. Vital signs were within normal limits. Initial evaluation showed non-specific electrocardiographic (ECG) abnormalities in the form of T-wave inversions in the lateral leads; however, she had two negative troponin assays. Her chest X-ray was unremarkable. The rest of her laboratory tests including complete blood count (CBC), basic metabolic profile (BMP), and liver function tests (LFTs) were within normal limits. The patient underwent an esophagogastroduodenoscopy (EGD), which revealed a non-bleeding gastric ulcer. Campylobacter-like Organism (CLO) test was positive for Helicobacter pylori, for which she received standard triple therapy. Her dysphagia was further evaluated with a barium swallow, which showed smooth extrinsic compression on the posterolateral aspect of the esophagus (Fig. 1). As the patient continued to have chest pain, she underwent a nuclear pharmacological stress test, which was high probability for ischemia. She was then taken for cardiac catheterization.
Cardiac catheterization revealed non-obstructive coronary artery disease. Due to the presence of extrinsic compression of the esophagus on the barium esophagogram, an aortogram was performed which showed an anomalous take-off of the right subclavian artery distal to the left subclavian artery (Fig. 2). This condition is known as dysphagia lusoria. In pursuing the workup of her chest pain, a computerized tomography (CT) angiogram was performed which confirmed the anomalous right subclavian artery coursing posteriorly resulting in smooth extrinsic compression of the esophagus (Fig. 3). There was no evidence of pulmonary embolism.