How an Elevated Creatinine Level Can Deter the Diagnosis of Acute Aortic Dissection

Acute aortic dissection (AAD) classically manifests with sudden, severe chest pain radiating to the back or abdomen, often described as ripping or tearing sensation. Considering its abrupt onset, the diagnosis requires a high index of suspicion prompting immediate imaging using computed tomography (CT) with contrast. However, the use of contrast is a relative contraindication in the patients with renal compromise and acute care physicians are often deterred from contrast use in these patients. Herein, we present an unusual case of hematuria as the presenting symptom of a developing the Stanford type-A AAD. A 65-year-old female presented with sudden, severe chest pain radiating to her lower back. She reported that her urine color was 'pink' on the previous day and was becoming more 'red-colored' as the day progressed. The next morning, she began feeling a 10/10 crushing-type chest pain that was relieved when she lay on her left side and was associated with nausea, vomiting, and diaphoresis. The urine analysis revealed gross hematuria. The laboratory findings revealed a creatinine of 1.3. Due to her elevated creatine levels and possible acute kidney injury, a computed tomography (CT) without contrast was performed initially, which did not reveal an AAD. However, the index of suspicion was still high for the AAD, after prompt discussions about the risk of using contrast and contrast nephropathy versus the risks of potential complications, if AAD was missed. Further evaluation with CT of the chest and abdomen, with contrast, was obtained with the patients' consent, which revealed a Stanford type-A AAD starting proximally from the aortic arch and extending to the common iliac. In conclusion, the clinical presentations of AAD are more heterogeneous. Hematuria in the presence of high index of suspicion and symptoms of AAD could indicate the extension of the involvement of the renal arteries. Prompt CT with contrast may be indicated despite relative contraindications from the laboratory findings.