A 26-Year-Old Male with Postural Dyspnea and Atypical Chest Pain

Case at a Glance

A 26-year-old male with a history of smoking presented with a six-month history of persistent left-sided chest tightness and significant postural dyspnea, which improved in a supine or slouched position. Despite an extensive workup including normal cardiac and advanced pulmonary imaging, he had elevated inflammatory markers. The recent onset of wheezing led to a clinical diagnosis of asthma, though atypical features suggest a multifactorial etiology potentially involving GERD and a musculoskeletal breathing disorder.

Patient's Story

A 26-year-old male, with a BMI of 28.7 kg/m², presented with a perplexing and frustrating six-month history of persistent left-sided chest tightness, which he described as a sensation of 'fullness' or a 'bulge.' This discomfort would occasionally radiate to his upper left back. The most prominent and unusual symptom was shortness of breath that was markedly dependent on posture; it worsened significantly when he was sitting or standing upright and was almost completely relieved when he slouched or was in a supine position. The patient also reported a subjective observation that his left chest wall appeared more prominent than the right. He had recently quit smoking but acknowledged continued exposure to secondhand smoke.

Initial Assessment

The patient had consulted multiple specialists, including pulmonologists, a cardiologist, and an orthopedic surgeon, without a definitive diagnosis. On initial presentation, his oxygen saturation was consistently normal (98-99% on room air), even during episodes of dyspnea. An orthopedic examination ruled out common musculoskeletal causes like costochondritis. The patient was empirically treated for gastroesophageal reflux disease (GERD) with a proton-pump inhibitor (Pantoprazole), and he reported one episode of scant hemoptysis after missing a dose, suggesting a possible GERD contribution to his symptoms.

The Diagnostic Journey

An extensive diagnostic workup was performed to identify the etiology of his symptoms:

• Cardiovascular Evaluation: A 2D echocardiogram was largely unremarkable, showing only mild left ventricular hypertrophy (LVH) and trace tricuspid and mitral regurgitation with a preserved left ventricular ejection fraction of 55%. These findings were deemed insufficient to explain his clinical presentation.
• Pulmonary Evaluation: Multiple chest X-rays and a high-resolution computed tomography (HRCT) scan of the chest revealed normal lung parenchyma and airways. A diffusion capacity study was also within normal limits.
• Laboratory Studies: Blood tests indicated a low-grade inflammatory state, with an elevated C-reactive protein (CRP) of 8.4 mg/L (normal <5 mg/L) and an erythrocyte sedimentation rate (ESR) of 23 mm/hr (normal <15 mm/hr).
• Gastrointestinal Evaluation: An abdominal ultrasound was unremarkable.

Final Diagnosis

After several months, the patient developed new-onset wheezing, which was a significant change in his clinical course. This was particularly triggered by minimal exposure to cigarette smoke. Based on this development and his symptom profile, a new consulting pulmonologist established a working diagnosis of Asthma. The persistent postural dyspnea and chest wall sensations were considered atypical features, possibly indicative of a co-existing Musculoskeletal Breathing Pattern Disorder (e.g., diaphragm dysfunction or rib cage mechanics abnormality). Gastroesophageal Reflux Disease (GERD) was also considered a significant contributing factor.

Treatment Plan

A multi-faceted treatment plan was initiated:

• Pharmacotherapy: The patient was prescribed a comprehensive asthma regimen including an inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) combination (Budesonide/Formoterol - Symbicort), a xanthine derivative (Acebrophylline - AB Phylline-N), and a leukotriene receptor antagonist (Montelukast/Fexofenadine - Telekast-F).
• GERD Management: Continued daily use of Pantoprazole was reinforced.
• Lifestyle Modification: The patient was counseled on the critical importance of strict avoidance of all tobacco smoke, including passive exposure.
• Further Investigation: A CT scan of the paranasal sinuses was recommended to rule out chronic sinusitis as a potential inflammatory trigger. A referral to a thoracic physiotherapist was also considered to assess and manage the postural and musculoskeletal components of his breathing disorder.

Outcome and Follow-up

The patient has recently commenced the new therapeutic regimen for asthma. However, he reported that wheezing has persisted despite initial use of his inhalers. The long-term outcome will depend on his response to optimized asthma and GERD therapy, the results of the sinus CT, and effective management of the postural component of his dyspnea. Close follow-up is required to titrate medications and to explore specialized physiotherapy if musculoskeletal dysfunction is confirmed to be a primary contributor to his symptoms. The role of secondhand smoke as a persistent trigger remains a key area for patient education and management.