Under the Radar: Back Pain and Acute Kidney Injury as Harbingers of Type A Aortic Dissection

Aortic dissection is a catastrophic vascular emergency with a high mortality rate if not diagnosed and managed in a timely manner. The classic presentation of thoracic aortic dissection includes the sudden onset of severe chest pain radiating to the back. Still, it may also present with atypical symptoms and signs of end-organ vascular compromise. We present a case of a 57-year-old female with a medical history of hypertension with poor medication adherence, major depressive disorder, chronic low back pain, and cocaine use disorder, who initially presented to the ED with worsening chronic low back pain, which was attributed to a musculoskeletal origin. She received analgesics, which improved the pain. Approximately 7 hours after presentation, the following morning, the patient developed acute-onset chest pain, prompting repeat evaluation, including an electrocardiogram and cardiac biomarkers, which revealed T-wave inversion in the lateral leads and elevated troponin levels. Based on these findings, the non-ST elevation myocardial infarction (NSTEMI) protocol was initiated. While the back pain and chest pain improved, her kidney function continued to rapidly deteriorate from the time of admission, prompting the team to perform a sonogram and subsequently an abdominal CT, which revealed a heterogeneous, hyperechoic right kidney with loss of corticomedullary distinction and possible aortic pathology. A CT angiogram of the chest, abdomen, and pelvis confirmed a type A aortic dissection extending from the aortic root to the iliac bifurcation. The dissection caused significant narrowing at the origin of the left common carotid artery and partial infarction of the right kidney due to involvement of the renal artery. The patient was transferred to a tertiary hospital for surgical intervention and remained hemodynamically stable; however, she opted against surgical intervention and left against medical advice despite extensive counseling. Clinicians should maintain a high index of suspicion for aortic dissection in patients with unexplained back pain, particularly when there are signs of multiorgan ischemia.