Case 3: Gait Instability and Elevated Troponin Level in a 16-year-old Boy

Presentation

A 16-year-old white boy presents to the emergency department after a fall. He was in the bathroom when he bent over to pick up an object and lost his balance. He fell forward and chipped his front teeth on the bathtub. He admits to feeling light-headed but denies loss of consciousness. Review of systems is positive for a temperature of 100.1°F (37.8°C), headache, rhinorrhea, and chest pain with cough for the previous week.

Vital signs record a temperature of 100.0°F (37.8°C), a pulse of 85 beats/min, a respiratory rate of 18 breaths/min, and blood pressure of 130/67 mm Hg. Physical examination reveals a well-developed, well-nourished, non–toxic-appearing boy with normal cardiopulmonary examination findings. A brief neurologic examination is notable for gait instability and generalized weakness.

Laboratory evaluation shows a normal complete blood cell count and electrolyte levels. An electrocardiogram is significant for normal sinus rhythm, normal axis, ST elevation in anterior leads, and T-wave inversions in anterolateral leads (Fig). Cardiac enzymes are collected and reveal a troponin I level of 7.021 ng/mL (7.021 μg/L) (reference range, 0.00–0.06 ng/mL [0.00–0.06 μg/L]), with normal creatinine kinase and creatine kinase–MB fraction levels. His 2-hour follow-up troponin I level is 6.905 ng/mL (6.905 μg/L). The patient is …