A 72-year-old woman presented to the hospital with 3 days of emesis, anorexia and generalized fatigue without any report of chest pain. Her physical examination was significant for mild confusion and bright red blood per rectum. On presentation she had bilateral lower extremity weakness, but was able to move both lower extremities; dorsalis pedis pulses were present bilaterally.

Initial laboratory examinations demonstrated a white cell count of 16.7 K/μL, creatinine of 3.0 mg/dL, aspartate aminotransferase/alanine aminotransferase of 1189/382 U/L, lactate of 4.5 mmol/L and a troponin of 0.52 ng/mL. ECG was unremarkable. An initial chest X-ray showed a dilated aortic arch and a modestly widened mediastinum.

A CT scan of the chest was not done. Several hours after presentation, the patient was noted to have flaccid lower extremities and diminished distal pulses, but with no skin changes or signs of distal ischaemia.

Duplex ultrasound of the lower extremities demonstrated biphasic waveforms of distal vessels with no areas of occlusion or evidence of embolisation. Transthoracic echocardiogram revealed a small pericardial effusion with grossly normal ventricular function; the aorta was not well visualised…….

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