Splinter haemorrhages as possible signs of myocardial infarction or pulmonary embolism

Abstract

Introduction/Objective Subungual splinter haemorrhages (SSH) are a common non-specific clinical sign which is easy to recognize. They can occur in conjunction with many medical conditions of various significance. They present as painless black longitudinal lines towards the distal part of the nail bed. The objective of this article is to present a patient with newly acquired chest pain, a differential diagnostic dilemma between acute myocardial infarction (AMI) and pulmonary embolism (PE) whose fingers show signs of SSH. Case report An emergency medical team (HMP) was dispatched to a location where a 58-year-old man was experiencing chest pain. They found the patient in a sitting position, reporting sudden onset of stabbing chest pain with no propagation and lasting a few hours. He stated that he had never before had similar symptoms. Upon examination, the patient was afebrile, hypertensive (180/100 mmHg), mildly tachycardic (84/min), and blood oxygen saturation was within normal limits (97% on room air). ECG: sinus rhythm, left axis deviation, S1 in D1, ST elevation ≤ 1mm in D2, D3 and aVF, ST depression from V4 to V6. The physical examination revealed SSH located on the nail beds of the hands distally. The patient was transported to cardiology where he was continuously monitored. Rising values of troponin T (310, 2628, 1507 ng/l) and creatine kinase (934, 1228 U/l) were noted. However, based on the rising values of D dimer and pulmonary artery multislice computer tomography (MSCT) findings, there were reasons to consider the possibility of pulmonary embolism (PE) as well. Conclusion Future research should aim at defining the connection between SSH and AMI and/or PE. This would be crucial in making a prehospital diagnosis, especially in countries that have huge cardiovascular disease public health problems, such as ours. A quick and simple exam of nailbeds on the hands of patients with symptoms of AMI/PE, but without significant ECG findings, could help with the differential diagnosis if SSH were found to be present.

Keywords

• subungual splinter haemorrhage
• myocardial infarction
• pulmonary embolism