Image of the month: Chest pain after cocaine use

A previously healthy 25-year-old male was admitted to the emergency department with severe chest pain soon after the consumption of 20 units of alcohol and snorting an unspecified amount of cocaine. The chest pain was described as a central dull ache, radiating to the jaw and exacerbated by deep inspiration, eating and coughing. On examination, blood pressure was 118/68 with a regular pulse of 108 bpm. Oxygen saturations were 99% on air. Heart sounds were normal, jugular venous pressure was not raised and the chest was clear. The anterior chest wall was tender to palpation. An electrocardiogram showed a sinus tachycardia, normal axis and no ischaemic changes. Blood tests on admission revealed an elevated troponin T of 44 ng/L (normal range, <14) Authors: Richard Bond, Edward Duncan and Angus Nightingale