Differential Diagnosis for Chest Pain with Associated Symptoms

The patient presents with chest pain radiating to the shoulders, back, chest, and jaw, accompanied by a history of UTI, AKI, pericardial fusion, ST elevation, and negative troponins, with no dissection or PE. Here is a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Acute Pericarditis: Given the patient's symptoms of chest pain radiating to the shoulders and back, history of pericardial fusion, and ST elevation without troponin elevation, acute pericarditis is a strong consideration. The condition is characterized by inflammation of the pericardium and can cause chest pain that improves with sitting up and leaning forward.

• Other Likely Diagnoses

  • Myocarditis: Although troponins are negative, myocarditis (inflammation of the heart muscle) can present with chest pain and electrocardiographic changes, including ST elevation. It's a consideration, especially if there's a recent viral infection or other inflammatory condition.
  • Pulmonary Embolism (despite negative initial tests): While initial tests for PE may be negative, the possibility of a small or evolving PE cannot be entirely ruled out without further testing, such as a CT pulmonary angiogram, especially if clinical suspicion remains high.
  • Esophageal Spasm or Esophagitis: These conditions can cause chest pain that radiates to the back and jaw, mimicking cardiac conditions. A recent UTI or AKI might not directly relate but could be coincidental or contribute to a systemic inflammatory state.

• Do Not Miss Diagnoses

  • Aortic Dissection (despite negative initial tests): Similar to PE, aortic dissection is a life-threatening condition that requires immediate diagnosis and treatment. Initial tests might be negative, especially if the dissection is small or not involving the main aortic branches. Clinical suspicion should remain high if the patient's symptoms suggest it.
  • Cardiac Tamponade: Given the history of pericardial fusion and symptoms suggestive of pericarditis, cardiac tamponade (fluid accumulation in the pericardial sac compressing the heart) is a critical diagnosis not to miss, as it can lead to cardiac arrest if not promptly treated.

• Rare Diagnoses

  • Spontaneous Coronary Artery Dissection (SCAD): A rare cause of myocardial infarction, especially in younger women, SCAD can present with chest pain and electrocardiographic changes. It's essential to consider in patients without typical risk factors for coronary artery disease.
  • Kawasaki Disease: Although more common in children, Kawasaki disease can occur in adults and presents with fever, rash, and desquamation, among other symptoms. It can lead to coronary artery aneurysms and should be considered in the differential for atypical chest pain presentations.