Post-cardiac injury syndrome (PCIS) is an underrecognized inflammatory complication of atrial fibrillation ablation that can mimic acute coronary syndrome. We present a 72-year-old man who developed pleuritic chest pain and pleural effusions 3 days after radiofrequency ablation. Using the 2025 European Society of Cardiology diagnostic criteria, we identified pleural-predominant PCIS. Anti-inflammatory treatment led to rapid recovery.

Cardiac tamponade is a life-threatening condition classically associated with compensatory sinus tachycardia due to impaired diastolic filling and reduced cardiac output; however, paradoxical sinus bradycardia is rare and may delay recognition. We report a case of a 43-year-old woman with obesity status post gastric sleeve, asthma, and hyperlipidemia who presented with two weeks of progressive dyspnea, pleuritic chest pain, and chest tightness following a suspected viral syndrome, with symptoms worsening supine and improving when leaning forward. Initial evaluation demonstrated muffled heart sounds, sinus rhythm with electrical alternans on electrocardiography, cardiomegaly on chest radiography, and a large pericardial effusion on point-of-care ultrasound without initial tamponade physiology. While awaiting further workup, she developed recurrent syncope with profound sinus bradycardia and transient pulselessness requiring vasopressor support. Transthoracic echocardiography revealed right atrial compression and right ventricular diastolic collapse consistent with acute cardiac tamponade. Urgent pericardiocentesis drained 1.3 liters of bloody, turbid fluid with immediate resolution of bradycardia and hemodynamic instability. Pericardial fluid analysis was exudative with inflammatory cells, and there was no evidence of malignancy. The patient was successfully treated with high-dose aspirin and colchicine without recurrence. Notably, the absence of compensatory tachycardia in this case contributed to delayed clinical recognition of tamponade physiology. This case highlights that cardiac tamponade may rarely present with paradoxical sinus bradycardia rather than tachycardia, underscoring the importance of maintaining clinical suspicion and performing prompt echocardiographic assessment, as urgent pericardial drainage can be life-saving even in nonclassical presentations.

Nephrotic syndrome is associated with a hypercoagulable state and can lead to serious thromboembolic complications. In patients presenting with pulmonary embolism without an identifiable provoking factor, hypoalbuminaemia and significant proteinuria should prompt consideration of underlying nephrotic syndrome. Awareness of this link is important to avoid delay in diagnosis.A woman in her 60s presented with exertional dyspnoea and pleuritic chest pain. CT pulmonary angiography confirmed bilateral pulmonary emboli and she was treated with apixaban. After discontinuing anticoagulation prematurely, she re-presented with worsening dyspnoea and fluid overload. Investigations revealed acute kidney injury, severe hypoalbuminaemia and nephrotic-range proteinuria. Repeat imaging demonstrated progression of pulmonary emboli and extensive abdominal venous thromboses. Renal biopsy confirmed phospholipase A2 receptor-positive membranous nephropathy. She was managed with anticoagulation, corticosteroids, rituximab and supportive therapy. Renal function subsequently stabilised, leaving chronic kidney disease with residual proteinuria. She remains under regular nephrology and haematology follow-up. This case emphasises the need to consider nephrotic syndrome in patients with unexplained pulmonary embolism and supports early urine protein testing as part of the initial assessment.

Empyema originating from a retroperitoneal source is rare due to the anatomical separation between the retroperitoneal and pleural spaces. We report the case of an 81-year-old man who presented with pleuritic chest pain following empirical antibiotic treatment for a urinary tract infection. Imaging revealed a large retroperitoneal gas-containing fluid collection and a left-sided loculated pleural effusion with a small pneumothorax. Pleural and retroperitoneal collection fluid both grew Escherichia coli suggestive of trans-diaphragmatic spread. A large hiatal hernia, structural defects of the hemidiaphragm and a Bochdalek hernia may also have been contributing factors. The patient improved with systemic antibiotics, percutaneous drainage of both collections and intrapleural administration of low dose tPA/DNase therapy. This case underscores the importance of considering extra-thoracic (especially abdominal) sources, especially in patients with structural diaphragmatic abnormalities.

Coccidioidomycosis is endemic to the Western Hemisphere and is rarely encountered in Asia, including Thailand. A detailed history, particularly of prior travel to endemic areas, is critical in refining the differential diagnosis and considering coccidioidomycosis.Here, we report an early adolescent male who presented with fever, non-productive cough and pleuritic chest pain of 1 month's duration. Radiologic findings were suggestive of pulmonary tuberculosis. Antituberculosis therapy was started, but there was no clinical improvement. However, on specific questioning, we learned that he had recently returned from Los Angeles, USA, before the onset of the illness. Hence, pulmonary coccidioidomycosis was suspected based on his travel history to an endemic region and the recognition that its clinical presentation can closely mimic tuberculosis. The diagnosis was confirmed by the results of pathology, cultures and molecular methods of transbronchial lung biopsy specimens. The patient gradually improved after fluconazole treatment.

Acute lupus pneumonitis is a rare but potentially life-threatening pulmonary manifestation of systemic lupus erythematosus, often presenting with nonspecific respiratory symptoms. We report a case of a 48-year-old female who presented with fever, dyspnea, and pleuritic chest pain. High-resolution computed tomography of the chest revealed bilateral pleural effusions. Autoimmune serologic testing showed strongly positive antinuclear antibody and anti-double-stranded DNA antibodies. After exclusion of infectious and alternative autoimmune etiologies, a diagnosis of acute lupus pneumonitis was made. The patient showed marked clinical improvement following systemic corticosteroid therapy. This case emphasizes the importance of early recognition and prompt immunosuppressive treatment to improve clinical outcomes.

Dupilumab is a monoclonal antibody approved to treat multiple type 2 inflammatory conditions. Dupilumab-associated hypereosinophilia is a well-documented side effect and typically does not lead to clinical symptoms or pathologic findings. We report a 65-year-old man with asthma and nasal polyposis who presented with pleuritic chest pain after two doses of dupilumab. Our evaluation revealed peripheral hypereosinophilia and pericardial thickening consistent with pericarditis on cardiac MRI. The patient was treated with ibuprofen and colchicine, did not require corticosteroids, and dupilumab was discontinued. Subsequently, his eosinophil counts normalized, and his symptoms resolved. To our knowledge, this is the first published case of dupilumab-induced hypereosinophilia followed by isolated pericardial involvement.

Systemic lupus erythematosus (SLE) is associated with increased cardiac morbidity and mortality and involves a range of cardiac pathologies. The most common of these is a simple pericardial effusion, though rarely this can be complicated by constrictive pericarditis. We present a case illustrating a rare SLE-mediated effusive-constrictive pericarditis. A 70-year-old female with a history of a prior stroke and coronary artery disease presented with 2 weeks of dyspnea, pleuritic chest pain, and fever. Her labs were notable for acute kidney injury with hematuria and proteinuria, elevated inflammatory markers, positive anti-nuclear antibody, low complement levels, and positive double-stranded DNA. CT scan of the chest showed circumferential pericardial effusion with echocardiogram and right heart catheterization confirming effusive-constrictive pericarditis. Clinically, she met diagnostic criteria for SLE and additionally underwent renal biopsy that confirmed SLE nephritis. The patient was started on colchicine, hydroxychloroquine, mycophenolate mofetil, and prednisone. A 3-month follow-up echocardiogram demonstrated resolution of the pericardial effusion and constrictive physiology. Effusive-constrictive pericarditis is a rare but important manifestation of pericardial disease in SLE. Treatment of the underlying SLE led to the resolution of the pericardial pathology.

Tjalma syndrome is a rare manifestation of systemic lupus erythematosus (SLE) characterized by pleural effusion, ascites, and elevated cancer antigen 125 (CA-125) levels in the absence of ovarian malignancy. We report the case of a woman in her 50s who presented with recurrent pleuritic chest pain, dyspnea, peripheral edema, ascites, and constitutional symptoms. Initial investigations were inconclusive, resulting in repeated admissions and multidisciplinary referrals. Subsequent immunological testing confirmed SLE. Given the constellation of serositis and elevated CA-125, a diagnosis of Tjalma syndrome was established. Treatment with immunosuppressants such as corticosteroids, hydroxychloroquine, and azathioprine resulted in symptomatic improvement. However, the disease course was complicated by constrictive pericarditis requiring pericardiectomy and later inflammatory arthritis requiring escalation of immunosuppression. This case highlights the importance of considering autoimmune etiologies in patients with unexplained multisystem effusions and elevated tumor markers, thereby avoiding misdiagnosis and unnecessary oncological interventions.

Background: While previous studies indicate an association between chest pain and favorable clinical outcomes in patients with pulmonary embolism (PE), the extent and underlying mechanisms of this effect remain inadequately defined. Methods: We investigated the prognostic value of chest pain with regard to in-hospital adverse outcomes and the association of chest pain with age and sex in consecutive patients with confirmed PE enrolled in a single-center registry between 2008 and 2019. Results: Of 858 patients (52% female) included in this study, 435 (51%) had chest pain at presentation. Chest pain was more prevalent in younger individuals aged 18-34 years (74%) compared to patients >34 years (46%). The prevalence of coronary artery disease (CAD) was similar in patients with and without chest pain (17.0% vs. 16.1%). Chest pain patients less frequently presented with elevated troponin levels (p < 0.001) or signs of right heart strain (RHS; p = 0.007) but more frequently exhibited imaging signs of pulmonary infarction (p = 0.001). Chest pain was associated with lower risk of adverse outcome (OR 0.35 [95% CI: 0.19-0.65]) and in-hospital mortality (OR 0.31 [95% CI: 0.13-0.74]). Multivariable models confirmed a prognostic effect independent of sex, comorbidities and results of risk stratification algorithms. Conclusions: In acute PE, chest pain is a favorable prognostic marker irrespective of sex. Chest pain patients are less likely to suffer from myocardial ischemia or show signs of RHS but more frequently show imaging signs of pulmonary infarction, suggesting pleuritic irritation rather than myocardial ischemia as the likely cause of pain.

Primary spontaneous pneumothorax (PSP) typically affects young, tall, slender males and is often associated with subpleural bleb rupture. While many cases occur at rest, sudden changes in intrathoracic pressure can serve as triggers. A 22-year-old male smoker (BMI: 21.2 kg/m²) presented with acute pleuritic chest pain and dyspnea immediately following a forceful sneeze. Clinical examination and radiography confirmed a massive left-sided pneumothorax. An emergent tube thoracostomy was performed, resulting in immediate lung re-expansion and symptomatic relief. This case highlights the importance of considering PSP in the differential diagnosis of acute chest pain following physiological maneuvers like sneezing, especially in patients with high-risk phenotypes.

Pheochromocytoma is a rare catecholamine-secreting tumor that has a highly variable presentation and may result in life-threatening complications. In the most severe cases, massive release of catecholamines can lead to refractory shock, acute cardiomyopathy, and multiorgan failure. The diverse clinical manifestations of pheochromocytoma often make diagnosis challenging in critical care settings. We report a 25-year-old woman who presented with acute abdominal pain, vomiting, pleuritic chest pain, and a productive cough and was initially managed as community-acquired pneumonia complicated by septic shock. She rapidly deteriorated, requiring intubation, vasopressor support, and advanced cardiac life support following cardiac arrest. Bedside echocardiography showed severe global left ventricular systolic dysfunction with an estimated ejection fraction of 20%-25%. During her stay in the intensive care unit, a femoral catheterization was performed for vascular access and hemodynamic monitoring. However, in the context of a catecholamine excess state, she subsequently developed acute ischemia of the left lower limb. Computed tomography angiography (CTA) showed extensive arterial occlusion, and an incidental 4 × 4 cm left adrenal mass was discovered. Follow-up biochemical testing showed markedly elevated plasma metanephrines and normetanephrines, supporting the diagnosis of pheochromocytoma. Despite treatment with thrombectomy, her limb ischemia was irreversible, necessitating an above-knee amputation. With supportive care and initiation of α-adrenergic and β-adrenergic blockade, her cardiac and renal function gradually improved. She was stabilized and referred for definitive surgical management. This case highlights that pheochromocytoma crisis may mimic septic shock and can present with severe cardiomyopathy and limb-threatening arterial thrombosis. Early consideration of catecholamine excess in unexplained refractory shock or multiorgan failure is important, since early diagnosis and targeted treatment can be lifesaving and help prevent irreversible complications.

Rhabdomyosarcoma (RMS) is an uncommon malignant soft-tissue tumor, with diaphragmatic spindle cell RMS being extremely rare in adults. A 41-year-old male patient had progressive breathlessness and right-sided pleuritic chest pain. Imaging and biopsy that includes X-ray, computed tomography, magnetic resonance imaging, histopathology, and immunohistochemistry established a large thoracoabdominal spindle cell RMS. Early diagnosis, careful imaging, and combined treatment were important, and they helped increase knowledge of this unusual entity.