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 Information contained in "Ask the Experts" is for informational and educational purposes only. Such information is not intended to replace, and should not be interpreted or relied upon as, professional advice, whether medical or otherwise. I have read the complete MDA Ask the Experts' Disclaimer, understand and agree to its terms.


SUBJ (04/98): DMD AND UNEXPLAINED CHEST PAIN

My son has Duchenne MD, diagnosed at 17 months, and he is now 15 and a half years-old. I had a brother who had DMD and currently have an 11 year-old nephew with DMD. My son has been experiencing chest pains for over a year. The pain seems to be located in the center of his chest. He gets several pains daily. They do not cause him a great deal of pain and they do not limit his daily routine. He may on occasion have a hard time taking a deep breath. He has had a spinal fusion with metal rods two years ago. He does sit very straight. His latest EKG showed that he has a noisy baseline and somewhat decreased voltages in both frontal and horizontal leads. He wore a holter monitor for 24 hours to see if his pains showed up on this test. This showed the underlying rhythm is "sinus" with brief "junctional" rhythm during sleeping hours. He had three rare APCs, a rare single PVC and one ventricular couplet. When he pushed the button during a chest pain and shortness of breath there was no correlation with these symptoms on the monitor. A subsequent echocardiogram, done three months ago, showed a very poor acoustic window. The results did not show any major problems.

A barium swallow showed no reflux. However, he has all the symptoms of reflux — acid taste in his mouth and a burning pain in his chest. He is currently on 150 mg. of Zantac two times per day and this has helped with the burning and acid taste.

He also has decreased pulmonary function test results. He has marked restrictive lung disease. However, his latest blood gas results were within normal limits.

Is there any explanation why he still gets chest pains? My son states that these chest pains are not the ones associated with reflux. They are a different discomfort. Have you seen other DMD patients with similar complaints?

REPLY [1] from MDA: Robert E. McMichael, M.D., MDA Clinic Director, Arlington, TX

DMD causes a cardiomyopathy. Clincally, this resembles the other genetic cardiomyopathies, of which many have now been identified. The abnormalities in the heart muscle can cause chest pains, even if there is no congestive heart failure. Treatment by a cardiologist might include a beta blocker drug such as Inderal (propranolol) or Tenormin (atenolol). If there is any reason to suspect congestive heart failure, then he might be treated by a diuretic (fluid pill) or an ACE inhibitor (a drug that reduces retention of salt and water). If your son could not get a good echocardiogram, he could possibly have a transesophageal echocardiogram if the cardiologist thought that might find some more information about abnormalities of the heart muscle or the heart valves. Prolapsing mitral valves can be associated with chest pains. I am not able to tell you for sure whether it would be worthwhile to do the transesophageal echocardiogram.

If your son has reflux, he may still get chest pains even though he is on Zantac. Prilosec and Prevacid are more powerful drugs for acid that he might try to see if they provide additional relief from the pain. Not all esophageal pains are like heartburn. Pain from reflux can even resemble the pain of a heart attack.

Assuming that your son has had x-rays to rule some problem inside of his chest, he might have some chest wall pain. That would be a musculoskeletal pain. Scoliosis, even after surgery, could potentially cause such pains.

Some people (including my patients) have chest pains and despite the investigations you cannot ever know the cause for sure. These are the main things that occur to me. You might want to discuss them with your son's doctor again to see what he thinks, because he or she will have a lot more facts available than I do about hour son's specific condition.

REPLY [2] from MDA: Irwin M. Siegel, M.D., MDA Clinic Director, Chicago, IL

Chest pain in DMD is usually due to a cardiac, respiratory, or gastrointestinal problem. Spinal fusion per se should not cause chest pain except insofar as rib excursion during inspiration may be restricted and it is, of course, possible to have referred pain to the chest from problems in the back. Other orthopaedic causes of chest pain include sterno-clavicular synovitis or arthritis or costo-chondral arthritis. These conditions are usually found in the older patient, but should be considered in a differential diagnosis. They are easily managed with medication and/or steroid injection. My concern here is the complaint of shortness of breath. It would appear that an adequate work-up has been conducted. Nonetheless, I think a cardio-respiratory specialist should take a very long and detailed look at this patient.


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