A 21-Year-Old Male With Multiple Episodes of Chest Tightness and a Markedly Elevated Troponin

A 21-year-old male with no past medical history presented to the Emergency Department (ED) with intermittent severe substernal chest pain beginning 40 hours earlier. The chest pain began at 1:30 am on the day before admission, shortly after he awoke, was retrosternal, pressure-like, 4/10 in severity, slightly aggravated by inspiration, and lasted approximately four hours. The chest pain was preceded by dizziness. It was not severe enough to interrupt plans to go meet friends at 2:00 am. The pain resolved spontaneously; however he had a second episode the following morning at 6:00 am, this time waking him from sleep and with radiation to the base of his neck and right arm, was more severe (7/10) and aggravated both by inspiration and by lying on his right or left side. The patient's chest pain resolved spontaneously after three hours so he decided not to go to the ED. After a third severe episode occurred, he decided to go to the ED.

The patient denied any recent viral illnesses or illicit drug use. He works at a meat smoking company where he cleans the meat smoking generators. He had never experienced this type of pain before. In the ER, the patient's vitals were within normal limits: 127/75 mmHg, 90 bpm, RR 18, temp 99.4 C. His ECG was normal without dynamic ischemic changes. Initial troponin was 29 ng/mL. The patient was chest pain-free throughout his two-day hospitalization and had no abnormalities on telemetry monitoring.

Past Medical History: none
Social History: (+) tobacco use, 2 cigarettes per month    (-) drug or alcohol use/abuse
Medications: none



trop-I (ng/ml)

CKMB (ng/ml)

CK (U/L)

7/31 23:00




8/1 01:00




8/1 05:30




8/12 (outpatient)




CBC and Chem-7 were within normal.
Utox negative.
LDL 75mg/dL HDL 34mg/dL. HbA1c: 5.7 TSH normal.
ESR/CRP just slightly above upper limit of normal. HIV nonreactive.

Inpatient Diagnostic Testing:
CT Thorax with contrast: negative for PE, dissection or other abnormality
Cardiac Catheterization: non-obstructive 30% stenosis in mid LAD, otherwise no coronary artery disease
Echocardiogram: normal LV and RV function without valvular or other abnormalities
Cardiac MRI: normal LV and RV function without regional wall motion abnormality, absence of abnormal T2 signal, no first pass or delayed gadolinium enhancement abnormality

What is the most likely explanation for the troponin-I elevation?

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