Breast pain from DCS?

[DocVikingo]

Hi PastorB,

This issue has been raised in the journal of Undersea and Hyperbaric Medicine. specifically (Undersea Hyperb Med. 2006 Mar-Apr;33(2):77-9) Decompression illness presenting as breast pain.Trevett AJ, Sheehan C, Forbes R. Stromness Surgery, John Street, Stromness, Orkney, Scotland, UK KW16 3AD:

"We present two cases of decompression illness in women in whom the initial symptom causing distress after completion of the dives was breast pain. Both women were also subsequently found to have a patent foramen ovale. We postulate that breast pain may be an unusual under-recognized manifestation of decompression illness."

I also know of a SCUBA instructor and another woman who relatively recently experienced repeated episodes of severe breast pain after diving and both were found to have patent foramen ovale (PFO) (*see below) upon appropriate investigation.

Should your wife develop any signs or symptoms of possible DCI on subsequent dives, full evaluation by a diving medicine savvy doctor would be prudent. DAN (DAN Scuba Diving Medical Services) may be able to provide the names of recommened practioners in your greater geographical area.

Helpful?

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

* To read up on PFO and SCUBA, see this Diving Medicine forum thread on the topic:

http://www.scubaboard.com/forums/diving-medicine/203215-dci-hole-heart.html

 

[Gene_Hobbs]

This issue has been raised in the journal of Undersea and Hyperbaric Medicine. specifically (Undersea Hyperb Med. 2006 Mar-Apr;33(2):77-9) Decompression illness presenting as breast pain.Trevett AJ, Sheehan C, Forbes R. Stromness Surgery, John Street, Stromness, Orkney, Scotland, UK KW16 3AD:

This journal article is RRR ID: 5024

 

[ESG]

I did a 2.5 hour dive with my boyfriend. We completed our deco according to my dive computer plus an extra 5 or so minutes, followed by a very slow ascent from 20 feet. We also did stops at 60, 50, 40, 30 feet. After the dive we waited on the surface for 20 minutes before moving and then slowly carried our gear up the stairs at Madison Blue. We got lunch after the dive and I noticed my boob was itchy! I went into the bathroom and noticed a very large bruise on my breast. On the way home I breathed pure oxygen for about an hour, all symptoms went away, although the pain did increase to an extent in the car and then began to go away. Had my symptoms not gone away, I would have gone to the chamber (10 min away from my house, maybe I should have gone anyway)...

I think my drysuit inflator may have caused circulations problems in that area. I recently began to suffer from Migraine headaches and plan on having a PFO test done. Not sure if this was helpful to the OP, but I would classify my case as an example of a boobie bend. My boyfriend, who completed the same dive was symptom free. I was extremely well hydrated and warm during the dive.

 

[DocVikingo]

Hi ESG,

The two women I mentioned above also reported being very well hydrated and warm during their dives, and indicated their thermal protection fit appropriately.

Interesting, no?

Regards,

DocVikingo

 

[PastorB]

DocVikingo,
Thank you for the information. When the diagnosis of DCS was made in Aruba at the local Dutch hopsital, a chest x-ray, EKG and blood gases were checked. The EKG computerized analysis said that she might have a anterior atrial infarct. So.... this weekend she had an cardiolite stress test that included ejection fractions. Test came back negative. I would think that this would have shown a PFO?? I thought that PFO's were only associates with new borns and tetrology of fallot? If you're wondering about how I might know this, I taught A and P for 10 years at the University of Central Florida to all the premed students. Once I am appreciative for your help.

 

[DocVikingo]

Hi PastorB,

I thought that PFO's were only associates with new borns and tetrology of fallot? If you're wondering about how I might know this, I taught A and P for 10 years at the University of Central Florida to all the premed students.

The Diving Medicine forum thread I linked in my initial response answers many of your questions.

In the meantime, here are a few points made an article I wrote for my "Ask RSD" column in Rodale's Scuba Diving some years back.

Patent foramen ovale (PFO) is an abnormal opening between the right and left upper chambers of the heart (atria). It is normal for blood to flow through a small opening (known as the foramen ovale) between these two chambers during fetal development when the lungs are inoperative and blood is oxygenated by the mother. At the moment of birth, however, changes in chamber pressures cause this membranous opening to close, shunting blood to the now functioning lungs. While usually the seal is entire and permanent, this is not always the case; about one in every four persons (~25-30% of the general population) has an incomplete closure of varying size. Without complete closure, blood can flow from the right to the left side of the heart without passing through the lungs.

Because the left side of the heart is the "high pressure side," the majority of otherwise healthy persons with PFO, many with only small openings, are unaware they have the condition. However, given a shift in the normal pressure gradient between the atria, blood can flow in the wrong direction. Such shifts can be occasioned by sneezing, coughing and SCUBA equalization maneuvers such as the Valsalva and similar pressurization techniques. For divers, this means inert gas bubbles in the venous system can be arterialized.

BTW, PFO is an atrial septal defect (ASD), while tetralogy of Fallot almost exclusively involves defects of the bottom two chambers of the heart (ventricles) and associated plumbing. They include a hole between the ventricles (ventricular septal defect or VSD), often rather large, but not between the atria.

The EKG computerized analysis said that she might have a anterior atrial infarct. So.... this weekend she had an cardiolite stress test that included ejection fractions. Test came back negative. I would think that this would have shown a PFO?

EKG and stress tests involving radionuclides such as Cardiolite are good at revealing what they were primarily designed to reveal. However, PFO is not among these. Arguably the gold standard for diagnosing PFO is transesophageal echocardiogram (TEE) with contrast injection and use of the Valsalva maneuver, although transcranial Doppler (TCD) with contrast injection and Valsalva also appears quite accurate.

Helpful?

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

 

[Dr Deco]

The new posts by Doc V were very enlighting to me. I was not at all aware of breast pain and DCS.

Many thanks for these replies!

 

[TSandM]

The heart can be regarded from a number of points of view: Anatomy, which includes defects like PFOs; function, which includes wall motion and valvular competence/stenosis; perfusion, which looks at whether the circulation to the various areas of the heart is adequate, at rest and under load; and electrical, which looks at whether signal generation and conduction in the heart are normal.

Anatomy is most frequently evaluated by echocardiography or by cardiac catheterization. PFOs are difficult to "see"; their presence is most frequently diagnosed by their effect, which is to allow blood to cross between the atria. Since we can't see small amounts of blood moving slowly, we use injected bubbles, as they are much easier to track. Transesophageal echocardiography is the gold standard for this, although transcranial Doppler (which doesn't look at the heart, but just looks at the arrival of bubbles in the cranial arterial circulation) is also a good test (less widely available).

Electrocardiography shows us the generation and propagation of electrical signals through the heart. When it is abnormal, it can be an indicator of heart muscle damage or inadequate circulation, which is why your wife was sent for a stress test. Electrocardiography can give us some very indirect clues about anatomy, but says nothing about small holes between chambers.

Stress tests, whether exercise or chemical, and cardiac catheterization, are ways of evaluating the perfusion of the heart structures. Stress tests do this by increasing cardiac workload and looking at either direct or indirect evidence of underperfused areas of muscle. (They use either electrocardiographic changes that suggest unhappy muscle cells, or radiography imaging of where the blood is actually going). Cardiac cath injects dye directly into the coronary arteries and gives us a picture of where narrowings are, and where blood is able to go and where it cannot. Cardiac caths can give us a good picture of some kinds of abnormal openings in the heart, but are not good for PFOs because the flow rate across them is too small.

Hope this information helps you make sense of the tests your wife has had done and what information can and cannot be gleaned from the results.

 

[JTemple]

Little late to the thread....

When I had skin bends in Manado last April, which required 3 rides in the chamber, it hurt like hell, and mostly in my breasts. Especially when driving down the pot hole-filled street on the way to the chamber! Based solely on my experience, the breast pain is a symptom of the hit.

Tell her I understand completely how she felt, she is not alone!

And I do have a PFO.

Hi ESG,

The two women I mentioned above also reported being very well hydrated and warm during their dives, and indicated their thermal protection fit appropriately.

Interesting, no?

Regards,

DocVikingo

Doc,
Yes, interesting, as the opposite was true for me. My profiles were fine all day, no violations, but on my 3rd dive, after almost 2 hours of surface interval, I got quite cold as there was a chilly thermocline. Even the DM came up with his teeth chattering. It was the only thing remarkable about the entire day.

 

[PastorB]

To all that have been following the thread, adding and giving counsel and offering advice, I am appreciative. I took the suggestions and had my wife go through all the testing. EKG's resting and stress, Cardiolight studies, Nuclear Med. studies and most recently, last week, an ultrasound to R/O PFO. I am quite happy to report that all is well. No PFO! Still, a lot of speculation about the extreme breast pain. Through this experience I we have learned several things.
1. We will be purchasing DAN insurance. Still waiting to hear if our current provider will be helping with the over $4,000 bill from hospital, doctor, lab, and chamber in Aruba.
2. We will both be well rested and hydrated before we dive and just from what is offered on the boat.
3. No more deep, consecutive dives. Dive a day, rest a day.
4. I will pay more attention to the dive tables/computer when it comes to surface interval time/nitrogen absorption and NOT to the dive master.
This was a very costly/emotional experience for us, mainly her as she was the one who had the DCS. We have greatly benefited from the diving community on this forum. To all: thanks again.
Rev. Alan Bosmeny