18 y.o. male h/o asthma presenting with chest pain this AM. Pain was substernal, crushing with intermittent sharpness, and has been waxing and waning all day. CP is pleuritic, not positional. Also reports some malaise, decreased appetite, nausea, and headache for the last 3 days.
VS wnl, NAD, no murmurs on exam.
What do you think he has?
The patient resulted with a Trop of 4 and ESR of 17. He has both myocarditis and pericarditis, or myopericarditis
Myopericarditis — When acute pericarditis is present, myopericarditis has been diagnosed by the detection of one or both of the following in the absence of evidence of another cause
- Elevation in serum cardiac biomarkers, such as cardiac troponin I or T
- New or presumed new focal or global left ventricular systolic dysfunction on imaging studies
Myocarditis and Pericarditis generally have the the same etiologies- a very long list which includes viral The most frequent viruses encountered in Western Europe and North America include Coxsackieviruses, (especially B), adenoviruses, cytomegaloviruses, echovirus, influenza virus, Epstein Barr virus, Human Herpes Virus 6 (HHV6), hepatitis C virus, parvovirus B 19 bacterial, spirochetal ,rickettseal,cardiotoxin, collagen vascular disorders, and hypersensitivity reactions. Can see full list at http://www.uptodate.com/contents/image?imageKey=CARD%2F56995&topicKey=CARD%2F4930&rank=1~30&source=see_link&search=perimyocarditis&utdPopup=true
Labs: CBC, Cardiac enzymes, ESR/CRP
Management: In the absence of significant myocardial failure, management of myopericarditis is similar to acute pericarditis, but admission is required for monitoring in all cases, while programs for outpatient management of low risk cases of acute pericarditis have been proposed
Depending upon the severity of pericarditis, and individual medication response, 1.2g to 1.8g of ibuprofen daily. Alternative protocols include aspirin (for instance 800 mg every 6 to 8 h followed by gradual tapering of 800 mg every week for a treatment period of three to four weeks)
Steriods should only be used if NSAIDs fail.
IVIG in severe cases
If more severe or has more cardiac compromise, then is considered Perimycarditis and should be treated as myocarditis.
Bonus Board Question from Emergency Medicine Examination and Board Review:
A teenage girl with a history of lupus presents to the emergency department with complaints of chest pain and difficulty breathing. The presence of which of the following is an indication for performing emergency pericardiocentesis?
A. Chest x-ray demonstrating severe cardiomegaly.
B. Electrocardiogram with severe, diffuse ST segment changes
D. Echocardiogram with pericardial effusion and bilateral pleural effusions.
E. Echocardiogram with a large pericardial effusion, tachycardia, and hypotension.
In a patient with documented large effusion on echocardiogram and the presence of tachycardia and hypotension, consideration should be given toward the placement of an emergent pericardiocentesis catheter. The indications for emergent drainage of a documented pericardial effusion include signs of hemodynamic instability such as tachycardia, hypotension, poor perfusion, shock, and acidosis. The presence of cardiomegaly, EKG changes, hepatomegaly, and an echocardiogram with pericardial effusion and pleural effusion may indicate the presence of pericardial effusion, but are not indications for emergent drainage.