three weeks prior to this presentation , she was evaluated in the emergency room for similar complaint and was discharged after having normal blood and imaging tests including cardiac enzymes , electrocardiogram ( ekg ) , and chest x - ray .
her chest pain was described as sharp , constant , 6/10 in intensity , located in the substernal area , radiating to the back , no exacerbating factors , and improved by non - steroidal anti - inflammatory drugs ( nsaids ) .
she had no previous history of rash , prior shingles , or lower back pain .
she had a past medical history of hypertension and was taking amlodipine and metoprolol at home .
she was a chronic smoker , smoking an average of five cigarettes a day for more than 20 years , but denied any alcohol or illicit drug use .
her vital signs were significant for mildly elevated blood pressure of 160/98 mmhg with a pulse rate of 75/min . on examination , she had normal pulses , a normal heart rate , and rhythm without any murmurs or gallops .
there was no chest wall tenderness , abdominal discomfort or costovertebral angle tenderness , and pedal edema .
initial ekg showed normal sinus rhythm at 86 bpm , normal axis with no evidence of st elevation or depression ( fig .
routine blood tests were done , which showed normal values of complete blood count , basic metabolic panel , liver function tests , tsh , coagulation profile , lipid profile , and serum cardiac troponin i ( ctni ) .
other labs revealed esr 25 mm / h ( normal 020 mm / h ) , crp 6 mg / l ( normal < 5 mg / l ) , and d - dimer 1.51 mg / l ( normal < 0.5 mg / l ) .
no other significant abnormalities were noted . a list of differential diagnoses including acute myocardial infarction , acute pulmonary embolism , aortic dissection , myocarditis , pericarditis , and musculoskeletal pain was made
. acute myocardial infarction and pericarditis were ruled out with the presence of normal ekg , normal ctni , esr , and high normal crp .
ct angiogram of the chest with contrast ( cta ) was obtained , which showed a protrusion of the medial wall of the descending thoracic aorta into a thickened aortic wall indicative of a penetrating atherosclerotic ulcer with imh ( fig .
transthoracic echocardiogram ( tte ) showed normal left ventricular size , wall thickness , and systolic function ( ejection fraction 
exercise stress test did not reveal any signs of myocardial ischemia . with the normal findings of cardiac workup and ct angiogram , pau with imh was diagnosed as a cause of recurrent chest pain .
ct angiogram of chest with contrast ( a ) transaxial and ( b ) coronal planes demonstrating a penetrating atherosclerotic aortic ulcer ( blue arrow ) with a mural hematoma approximately 2.3 cm in the largest transverse diameter and 1.25 cm in the largest thickness ( blue arrow ) .
as her condition did not require immediate surgical intervention , she was scheduled for outpatient follow - up and was counseled about medication compliance for anti - hypertensive and smoking cessation .
after 2 weeks , she followed up in the clinic where she stated that her chest and back pain had resolved .
her blood pressure was controlled with bp of 130/80 mmhg and also she had successfully quit smoking .
acute aortic syndrome ( aas ) is a constellation of aortic dissection , imh , and penetrating atherosclerotic disease . with recent developments in diagnostic modalities
, pau has been frequently identified over the past few years with 2.37.6% estimated prevalence in symptomatic patients with aas , but its background and actual incidence remains unknown ( 5 , 6 ) .
pau usually develops in old age , atherosclerotic disease , coronary artery disease , hypertension , hyperlipidemia , a strong smoking history , and renal disease ( 7 , 8) .
it can not be differentiated from aortic dissection by symptoms alone at initial emergency room visit , where exclusion of classic aortic dissection is crucial ( 5 , 8) .
pau can be found in the ascending and descending thoracic aorta while the latter was being more common .
pau , known as a disease of the intima , can start as a benign atherosclerotic plaque in the aorta , which can gradually progress to deep media layer associated with imh due to disruption of vasa vasorum that may be a nidus of aortic dissection ( 9 ) .
it can be associated with complications such as acute aortic dissection , aortic rupture , aortogastric fistula , and false aneurysm ( 4 , 10 , 11 ) . moreover
, the risk of aortic rupture was higher in patients with pau ( 40% ) compared with patients with type - a ( 7% ) and type - b dissections ( 3.6% ) ( 9 ) .
it is worth noting that the understanding of pau in the literature came from imaging studies rather than histopathologic findings ( 8 , 9 ) . because of its vague presentation
therefore , pau is often found while the patient is undergoing diagnostic tests to rule out other pathologies .
traditionally , pau was diagnosed by aortography ; however , since the early 1980s , cta , mri , and tte have replaced aortography to diagnose aortic pathology .
table 1 summarizes the radiologic findings of pau ( 6 , 8 , 12 , 13 ) . however , cta is the best diagnostic choice in pau ( 8) . management of pau depends on several factors including the presence of symptoms , location of ulcer , extent and size of the ulcer , and presence of imh ( 8 , 14 ) .
the presence of pau in ascending aorta with persistent symptoms , hemodynamic instability , imh , and progression of ulcer size are major predictors of adverse outcome which require early surgical intervention ( 14 ) .
radiologic findings of pau we here report the case of a 65-year - old woman with recurrent chest and back pain of unknown origin , later found to have pau with imh in the descending aorta as a cause of her chest pain .
there was a similar case reported in which a patient presenting with persistent chest pain was determined to have a pau in the descending aorta .
ct showed varying degrees of sub - adventitial hemorrhage in the thoracic aorta ; therefore , this patient underwent surgery successfully ( 15 ) .
reported a case of pau , which presented with chest and back pain of uncertain origin .
cta chest showed a pau in the ascending aorta associated with aneurysmal dilatation , which required immediate surgical intervention ( 16 ) .
the above cases highlight the importance of early detection and surgical treatment of pau to prevent adverse outcomes if ct scan findings were of concern .
interdisciplinary expert consensus from the european journal of cardio - thoracic surgery made the statement that medical treatment was indicated in patients with uncomplicated courses whereas thoracic endovascular aortic repair ( tevar ) , or surgical therapy , was considered in complicated cases including persistently symptomatic patients despite medical treatment , asymptomatic patients with large pleural effusions , imh , and large initial pau depth ( > 10 mm ) and diameter ( > 20 mm ) ( 14 ) . in asymptomatic patients who do not require surgical intervention , follow - up is recommended every 6 months for the first 3 years and every year thereafter with imaging techniques ( 14 ) .
since there was no surgical indication for our patient , she was conservatively managed with tight blood pressure control and smoking cessation .
she was symptomatically better and discharged to outpatient follow - up with further imaging studies . in conclusion
, pau is an underestimated aortic disease that can present with chest and back pain . until now
, there is no sufficient data in the literature to suggest which chest pain patient should undergo an extensive workup . individualized clinical judgment with a detailed history and thorough physical examination is a valuable tool in the evaluation of chest pain , and it is paramount to think of pau if chronic chest and back pain in elderly patients are unrelated to cardiac or musculoskeletal origin , where further diagnostic imaging might be necessary .
we mostly focus on the assessment of acute coronary syndrome and pulmonary pathologies in patients with chest pain but unfortunately we forget to consider other etiologies that may be equally dangerous
. since pau is one of the aas with a high risk of complications , we may miss this life - threatening diagnosis if we do not have a hunch and perform appropriate tests .
this work received no specific grant from any funding agency in the public , commercial , or not - for - profit sectors .
 chest pain is a very common symptom and can be of cardiac or non - cardiac origin . 
 it accounts for approximately 5.5 million annual emergency room visits in the united states , according to 2011 cdc data . 
 penetrating atherosclerotic aortic ulcer ( pau ) , an uncommon condition , is also a potential cause of chest pain . 
 we here report the case of a 65-year - old woman who presented with atypical chest and back pain . 
 the pain persisted for 4 weeks necessitating two emergency room visits . 
 initial tests were non - significant including cardiac troponins , an electrocardiogram ( ekg ) , and a chest x - ray on her first visit . upon her second visit , she underwent a computed tomography angiogram of chest with contrast which revealed a pau with an intramural hematoma in descending aorta . 
 the pau was finally diagnosed with an exclusion of other chest pain causes . 
 she was treated non - surgically with a blood pressure control strategy and pain management . after a 2-month period of smoking cessation and following the achievement of a controlled blood pressure 
 , she felt well without chest pain . 
Case presentation
Discussion
Conflict of interest and funding