Acute aortic dissection as a cause of shaking chills

An 81yearold woman was brought to the emergency department with acute onset of shaking chills. She had no upper respiratory tract symptoms and chest, back, or abdominal pains before the arrival to the hospital. Her only regular medication was a nifedipine for hypertension. On examination, she was illappearing and had shaking chills. The blood pressure was 170/87 mmHg in the right upper extremity and 165/81 mmHg in the left upper extremity, pulse of 68 per minute, respiratory rate of 28 per minute. The temperature was 36.3 degrees at the time of arrival, and it was elevated to 38.5 degrees 6 hours later. The remainder of other physical examinations was normal. Laboratory tests revealed whitecell count of 46×108/L, neutrophils of 27×108/L, hemoglobin of 10.8 g/dL, platelets of 16.9×109/μL, Ddimer of 5.6 μg/mL, and Creactive protein of 0.12 mg/dL. Urine test was normal. ECG was unremarkable. Chest Xray revealed the widening of the mediastinum (9cm size of horizontal diameter). The patient received physical examination from top to bottom, blood and urine tests, and 2 sets of blood cultures, urine culture in the emergency department. Noncontrast and contrast CT scan imaging