Acute chest pain (ACP) is very common among patients presenting to emergency departments. Nevertheless, ACP caused by esophageal foreign body is relatively rarely reported.

A 56-year-old man suffering from chest pain (increased pain for the last 9 h) was admitted to our hospital on October 25, 2015. After undergoing physical examination and laboratory blood testing, he was diagnosed with acute anterior myocardial infarction. Consequently, the patient underwent emergency percutaneous coronary angiography; however, no myocardial infarction signs were observed. Later on, the patient experienced respiration failure and therefore was transferred to intensive care unit. Cardiac ultrasound showed pericardial effusion, which was considered as the cause of shock. He then underwent pericardium puncture drainage and the circulation temporarily improved. Nevertheless, persistent pericardial bleeding, unclear bleeding causes, and clot formation induced poor drainage led to worsening of cardiac tamponade symptoms. Consequently, the patient underwent emergency exploratory thoracotomy, which revealed a fish bone causing pericardial bleeding. The bone was removed, and the damaged blood vessels were mended. Eventually, the patient was discharged in good clinical condition.

For patients with chest pain, it is necessary to consider the possibility of foreign body in the esophagus or even in the heart. Careful history taking and the corresponding inspection can help to avoid unnecessary damage and safeguard patients from unnecessary pain.

Chest pain is the early symptom of numerous life-threatening disease processes. The most common causes of acute chest pain (ACP) are acute coronary events (acute myocardial infarction or angina), aortic dissection, and pulmonary embolism. ACP caused by esophageal foreign body is relatively rare[1]. Most patients with ACP are accurately diagnosed and promptly treated based on the individual histories, blood biochemical tests, or imaging examination. Herein, we report the case of a patient with ACP as the chief complaint that was ultimately diagnosed as fish bone-induced myocardial injury.

Finally, the patient was diagnosed with fish bone-induced myocardial injury.

After removing the fish bone and mending the damaged blood vessels, the patient returned to ICU at 20:55. Reviewing the initial chest CT at local hospital (Figure 3), a strip-shaped high-density shadow at the bottom of the esophagus was found. After being repeatedly inquired of the medical history, the patient admitted to eating fish at dinner, but could not recall swallowing a fish bone.

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Figure 3 Chest computed tomography image. A strip-shaped high-density shadow was visible at the bottom of the esophagus (arrow).

The postoperative course was uneventful and CTN-I fell to 0.25 ng/mL. The patient was successfully extubated on day 3, transferred to thoracic surgery department next day, and discharged in good clinical condition after half a month.

Acute myocardial infarction or angina is the most common cause of ACP, which is mainly diagnosed by using ECG and blood biochemical test[2]. In our case, the patient was misdiagnosed with acute myocardial infarction. His emergency percutaneous coronary angiography was negative. Bedside cardiac ultrasound showed pericardial effusion and pericardium puncture drainage improved the circulation. Nevertheless, persistent pericardial bleeding, unclear bleeding causes, and clot formation led to poor drainage, eventually resulting in worsening of cardiac tamponade symptoms. Considering the possibility of coronary artery injury and lack of the capability of emergency coronary artery bypass at our hospital, our medical team was highly concerned that thoracotomy hemostasis would significantly increase the risk for the patient, while he was reaching the condition when it was no longer safe for him to be transferred to another hospital. We conferred with the patient’s family and obtained their consent for emergency exploratory thoracotomy. Finally, a diagnosis of fish bone leading to pericardial bleeding was confirmed.

Our patient was extremely lucky to survive this penetrating heart injury. Actually, in retrospect to the whole treatment, there are still many aspects worth reflecting on: First, the primary clinician failed to adequately and carefully examine the patient’s history. The existing literature shows that ACP caused by ingested fish bone resulting in esophageal or cardiac injury is not relatively uncommon[3-8]. Foreign body ingestion is an important diagnostic clue. Thus, the diagnostic challenge we faced with this patient was that he could not recall swallowing a fish bone, which partly contributed to the initial misdiagnosis. Second, chest CT examination is the preferred technique for suspected esophageal foreign body[9]. In this case, the patient underwent CT examination at a local hospital; however, the clinicians failed to observe a high-density shadow in the lower esophagus. Moreover, the primary clinician at our hospital did not personally read the chest CT, which further contributed to the misdiagnosis. Finally, we failed to timely recheck chest CT, cardiac ultrasound and so on after negative results of emergency coronary angiography, which led to further deterioration of the patient’s condition.

Therefore, for patients with chest pain, it is necessary to consider the possibility of foreign body in the esophagus or even in the heart. Careful history taking and the corresponding inspection can help to avoid unnecessary damage and safeguard patients from unnecessary pain.

Foreign body is a very rare cause of chest pain. Careful history taking and the corresponding inspection can help to avoid unnecessary damage and safeguard patients from unnecessary pain.