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Have chest pain. Combination of recurrent lung infection and Psoriatic Arthritis. Undergoing replacement IgG Therapy

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Practicing since : 1998
Answered : 1306 Questions
Hello Doc,

I have had chest pain for many years, they suspect that it is a combination of recurrent lung infection and Psoriatic Arthritis - I have had a shunt study which was positive - my body seems constantly inflamed.

I am undergoing replacement IgG Therapy (Intravenous)

I have had most studies done for the heart - including stress test and echo (all ok) - I have had a few CT's done but they have been inconclusive.

I have low 02 sats and low Blood O2 Gas - I am under the care of a respiratory physician

For some reason when lying down - my heart rate gets elevated, but when walking it lowers again - recently I have been feeling a sharp pain in my chest (never had the sharp pain) - it hurts in rhythm with my heart beet.

My O2 sats sit around 94-95 and they say this is because of the shunt, I have had a bubble study which showed no hole in the heart.

At present - I get vertigo a lot - especially when sitting down or standing up, however my blood pressure is never low - I have great deal of issue with my memory and I fear this is from a lack of O2 - my blod gas was borderline hypoxic - especially in the mornings, the sharp chest pain comes in the early morning hours around 3am - I take some spray under my tongue and I am not sure if that helps because I go back to sleep.

I have had clots in my arms before and I have high cholesterol - I always have high Uric acid in my blood work and I suffer from Gout a lot and Autoimmune issues (regardless of diet)

I seem to be fine when playing football etc, but when I relax for long periods I get pain and a feeling of fluid around my heart - it ONLY happens when stationary - i can often feel short of breath but only after sitting for more than 1-2 hours

I had a fundiplication operation to stop Gerd - during this operation my heart stopped (Vasal Vagel response) - not sure what else you need to know but I would like to stop the dizziness and the chest pain, it is scary being woken like that - i have had far too many CT's so I cant have a spiral angio - I have had an MRI of the heart (before the clots) and it all looks fine.

I have two O2 Sat devices at home and can do tests if you like.

I am constantly in pain from autoimmune arthritis - I no longer work because of this - They suspect Lupos and Psoriatic Arthritis.

Posted Mon, 4 Nov 2013 in Hypertension and Heart Disease
Answered by Dr. Sukhvinder Singh 46 hours later
Brief Answer:
please see details

Detailed Answer:
Dear Sir
1. Chest pain has many causes and needs to be dissected out before exact treatment can be started.
2. A pain which comes on exertion/ running/ using stairs/ exercise and gets revealed by rest is likely to be anginal (heart related). These pains are behind breast-bone and are like pressure of a heavy stone on chest. This may be associated with breathlessness. A pain which increases on touch or pressure, can be localized, elicit-able by particular movement and responds to local application of analgesics is morel likely to be musculo-skeletal. Pain associated with cough, bending, straining on stools, sharp shooting in nature, comes like a circular band around chest is more likely to be neurological. Pain arising from lung and its covering increases on cough or deep inspiration and lying on side of pain.
3. In Patients similar to history you have, a repeated chest infection with involvement of coverings of lung (pleura) can be a plausible cause for pain chest. Sharp pain which hurts with heart rhythm is not likely to be anginal in nature. However a clinical examination should be done to know the exact cause. Moreover if you can play football without chest pain and it comes after 2-3 hours of sitting, it is not likely to be anginal in origin.
4. The spray you are taking under the for sharp pain is likely to be glyceryl trinitrate (GTN). If it is so , this it self may be associated with increased heart rate and vertigo at times. You should take it only if recommended by your cardiologist/ internist.Low oxygen concentration can be a cause for vertigo. You need to get it evaluated , especially at time of exercise. I would also recommend you to get evaluated for postural hypotension (fall in BP on sudden standing.).
Hope this helps.
Feel free to discuss further.
Above answer was peer-reviewed by
Follow-up: Have chest pain. Combination of recurrent lung infection and Psoriatic Arthritis. Undergoing replacement IgG Therapy 1 hour later
Thanks Doc,

Awesome response -

Just to clarify a few things;

From the pain descriptions that you are mentioning, it would have seemed like a plural pain, however I have had a Video Assisted Thorascopy and it showed no inflammation in the Pleura - I do get many chest infections due to the Compromised Immune System - however I have been on antibiotics for some time.

The Vertigo is not related to the GTN spray - i only take this on occasion - I did have a large concussion so it is possibly from that - I did have a tilt test performed, but this was before the Vertigo appeared - is that the same test as I could repeat that.

The only time my sats drop is after being stationary for some time, it is also the only time that I get chest pain, until recently I was playing 3 - 4 games of high cardio sport a week, that is where the confusion comes in, all Doctors assume that if I am not short of breath while exercising that there is no possibility of Heart problem, in fact in the stress tests they stopped the test as I ran for too long and was not even tired.

The pain is definitely under the breast bone - at the bottom of the heart and can not be produced on demand - the only suggestion I ever got was a possibility of a thing called Prinze Metal Angina - which is the opposite of most issues, ie it only happens at rest.

I have a crackle when I exhale - it is quite audible - it almost seems like something is backing up in my lungs after I am at rest for long periods, it seems worse when sitting at a desk.

I am having huge problems with short term memory and nothing has ever been revealed on any heart investigations - a bit of valve regurgitation and some scladerma of a valve (spelling) .. but other than that nothing to speak of.

It is possible that it is my lungs coming back to normal after many years of infection and bronchioles clearing of infection - but I am unsure

I would like to rule out infection as I am always at high risk due to low immunoglobulan - I dont have an ear infection to justify the Vertigo

I do not get dizzy while sitting or lying down, it is only when I go to get up or go to lie down, I have reasonable blood pressure which is more towards the high side of things than low and I think the tilt test showed it does not change positionally.

I can be sitting down using an O2 sat montior at 90bpm and when I stand up and walk for 5 mins it will drop to 55-60BPM

I would like to know about this prinz metal thing in more detail (apparently it is rare) and I would like your opinion on a shunt causing this issue - ie could DE-oxyginated blood be pushed through my body more when I sit or stand or tilt my head?

Could the dizziness be from the head injury - ie inner ear crystal dis lodgement or bleed in the brain and could an infection be in my heart and brain?

Cheers in advance


Answered by Dr. Sukhvinder Singh 9 hours later
Brief Answer:
please see below

Detailed Answer:
Dear Sir
1. Post head injury vertigo or dizziness is well known phenomenon. You have to discuss this with your neuro-physician. Certain exercises help in reducing this in certain cases. Dizziness on standing up or lying down only can be due to other neurological problems like pathologies of cervical spine. The neuro-physician will also be able to throw light on that.
2. The kind of description you have given in the presence low immunoglobulins a condition called BRONCHIECTATSIS may be a possibility. Since it requires examination and an expert opinion of a lung physician (pulmonary medicine specialist ) , I would recommend you to see one. Repeated lung infections, with crackling sounds on expiration, shortness of breath in particular posture, low baseline oxygen aturation, shunting of blood in lungs, fall in saturation on walking can all be present in this condition. Low immunoglobulins predispose to this condition.
3. Prinzmetal's angina is pain chest caused by decrease supply to muscles of heart by sudden constriction (narrowing) of blood vessels of heart. It occurs mostly at rest. Young smoker males are more likely to have it. It is characterized by ST elevation in ECG and normal coronary angiogram. The most important thing to identify it is to get an immediate ECG which will show ST elevation which will respond dramatically to nitrates.
Hope this helps. Feel free to discuss further.
Above answer was peer-reviewed by
Follow-up: Have chest pain. Combination of recurrent lung infection and Psoriatic Arthritis. Undergoing replacement IgG Therapy 11 hours later
Thanks Doc, i will see an ENT and a Nuerologist for the dizzy spells and speak to my respiratory physician about the bronchiastasis thing.

With regard to poit #3 - i assume to test ST for Prinze Metal, I must be actually having the Angina while the ECG is running, this would be impossible as there is no way to trigger it, it is rather random and not constant.

Answered by Dr. Sukhvinder Singh 10 hours later
Brief Answer:
Please see details.

Detailed Answer:
Dear Sir
1. Normally the episode of Prinzmetal angina lasts for enough period to let you reach emergency room and get an ECG. Episodes lasting for few minutes , say less than 3 minutes, are unlikely to represent Prinzmetal angina.
2. We do trigger testing at time of coronary angiogram to confirm it, when angiogram is normal. But for an angiogram to be performed, you must have a proven clinical episode. There is no other way to test.
Above answer was peer-reviewed by
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