Acute Pericarditis in a 12-Year-Old Girl
M.J. is a 12-year-old African American female who presented
with trouble taking a breath which was abrupt in
onset, starting two hours prior to presenting and accompanied
with abdominal pain and fatigue which resolved
prior to her visit. Dyspnea was constant and not related to
position. There were no alleviating or aggravating factors.
Observations and Findings
Patient was alert and in no distress and spoke in full sentences.
Pmhx: bronchitis one year prior; no asthma, no cardiac problems,
no sickle cell disease
Meds: none
Social hx: no drugs or tobacco
Ros: no fever, lethargy, headaches, chest tightness, cough,
wheezing, foreign body aspiration, abd pain, vomiting, back
pain, dysuria, polyuria, polydipsia, rashes, swollen glands,
extremity pain, falls, or injuries
Physical: t-98.7, p74, rr12, bp 98/60, o2 sat 97% ra
Resp: ctab no crackles or wheezes
Cor: rrr, no m/r/g were appreciated
Diagnostic testing: CXR revealed a normal mediastinal silhouette,
clear lung fields with no consolidation, effusion or pneumothorax.
All other structures intact. EKG is shown for your review
(Figure 1).
Diagnosis
Acute pericarditis was determined by EKG, which reveals sinus
rhythm with sinus arrhythmia, and diffuse ST segment elevation
in at least two limb leads and all chest leads, especially v3-
v6. Lastly, no ST-segment reciprocal changes, no Q-wave features,
and T-waves are prominent and upright.
Discussion
Pericarditis is an acute or chronic inflammation of the pericardi
um. It is more common in males and most common in adolescents
and young adults. Causes could include AMI or post-MI
(Dresslerfs syndrome), be viral (coxsackie B, HIV) or bacterial in
nature, or be related to collagen vascular disease, radiotherapy,
local carcinoma, tuberculosis, uremia, or drugs (e.g.,
hydralazine, methyldopa, minoxidil, procainamide).
The most common type is fibrous and serofibrous occurring
from AMI, uremia, radiation, RA, SLE, or trauma. Other types
include serous, purulent, hemorrhagic and caseous.
Clinical signs: Pericardial friction rub: intermittent, positional best
heard when sitting forward at the lower left sternal border, louder
on inspiration. This can be difficult to detect and is present in
approximately 50% of cases. Classical features of pericarditis
are pericardial pain, friction rub, and a concordant ST elevation.
Differential diagnosis: Myocardial infarction, angina, aortic dissection,
dyspepsia, pneumothorax.
Testing: EKG, CXR (useful to detect pneumothorax and pericardial
effusion), PPD, HIV, ESR, CK, troponin (may be elevated
in viral), ANA, RF, 2d-echo, CT/MRI.
Symptoms: Sharp, central, retrosternal precordial pain that is
worse with deep inspiration, change in position, or exercise. May
be sudden or gradual onset. May be relieved with sitting forward,
or worse with lying back. Dyspnea is common, as are dry
cough and dysphagia. Low-grade fever is a common finding.
Patients could present with abdominal pain or just fatigue or
malaise.
Treatment
Options range from no treatment with bed rest to anti-inflammatories
(e.g., ibuprofen, indocin, prednisone), hospitalization
(pericardiocentesis), or surgery (pericardiectomy), depending
on age, severity and underlying cause.
Course of illness: Episodes may last one to three weeks;
future episodes can occur. One in five people have recurrence
within months of original episode. Repeated episodes may
be treated with colchicine.
Possible complications include pericardial effusion and cardiac
tamponade.
Patient Course
M.J. was sent to the ER for further evaluation. An echo revealed
no effusion. Initial workup labs were negative, and the patient
was discharged home on NSAIDs with close follow-up. Of
note: No instigating cause for this patient's illness was found but
a viral source is suspected.
Acknowledgment: Case submitted by Michael Talkar, MD,
family/urgent care physician, locum tenens currently on assignment
in Arizona.
