When chest pain conceals cord compression: compressive myelopathy mimicking NSTEMI in a hemodialysis patient

Abstract Background Acute quadriplegia due to compressive myelopathy is a rare but reversible neurological emergency, especially when diagnosed early. In patients with comorbidities such as diabetes and end-stage renal disease (ESRD), clinical presentations may be atypical, and elevated cardiac biomarkers like troponin may not reflect true myocardial ischemia. This can lead to diagnostic delays when spinal cord compression mimics cardiac conditions. Case presentation A 56-year-old male with diabetes and ESRD on hemodialysis presented with progressive quadriplegia. Three weeks prior, he had experienced chest pain and shortness of breath, prompting a diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) based on mildly elevated troponin (145 pg/mL), despite a normal ECG. He was treated for volume overload and sepsis secondary to a central line-associated bloodstream infection (CLABSI) and discharged in stable condition. One week later, he developed a weakness of his right leg, progressing to complete quadriplegia by the following week. Neurological examination revealed a sensory level at C6–C7 and motor weakness in all limbs. MRI of the spine showed compressive myelopathy at C8–T1, prompting urgent neurosurgical referral. Retrospective analysis suggested that his initial chest pain was referred pain from spinal cord compression rather than cardiac in origin. Conclusion This case highlights the importance of maintaining a broad differential diagnosis in patients with complex comorbidities. Elevated troponin in ESRD may be misleading, and clinicians must consider spinal pathology in the presence of neurological deficits, even when symptoms mimic cardiac events. Early recognition and intervention are key to preventing irreversible neurological damage.