SonoCase: 25 yr old positional, pleuritic, chest pain. “It’s just pericarditis” Really?

Had a great case the other week of a patient who was previously healthy (“great” because of what it reminds us all to do with this diagnosis) , and other than a girlfriend who he fought with too frequently causing him to go into panic attacks and hyperventilate, he doesn’t have any other stressors in his life – psychologic or drug-induced (yes, I mean cocaine). He came to the ED c/o positional chest pain, worse when lying flat and breathing in, has been persistent for over a week with a recent viral syndrome but no current fever, cough or respiratory distress. He looked well, but felt tired, had no energy to walk a few blocks and that has been worsening over the week, which is when he got into another fight with his girlfriend about coming into the ED for evaluation. Thankfully, he lost and came in.  He didn’t have any significant family history for cardiac disease, no one dropping dead unexpectedly, and had no risk factors for pulmonary embolism. His lungs were clear, and his heart had no murmur but with a rate of 100. EKG showed diffuse ST changes, CXR was negative (no prior one to look at and compare to). He even got labs ordered which were negative. I worked with a resident who was rotating through the ED and said, “It’s just pericarditis. I gave him Motrin and he feels better. I want to send him home.” Ok, this is not a mystery, it’s classic – as if he read the textbook! I know that many of you would likely do the same, and I almost did as well, but something about him having worse symptoms when walking a few blocks, made me wonder if he had any consequent effects of pericarditis. – so I decided to quickly look at his heart with a bedside echo:

Well, how about that! Pericardial effusions is a consequence of pericarditis, along with other bad things. And, this is why I wondered why people feel reassured that it’s “just” pericarditis. Well, maybe that’s in relation to the other diagnoses: acute MI, PE, dissection…. But, it is also a disease process that should be appreciated. The pericardium promotes cardiac efficiency by limiting acute dilation, maintaining ventricular compliance and helps atrial filling as well as shields the heart by minimizing external friction and acts as a barrier against infection and cancer. Viral infection is the most common cause of acute pericarditis and accounts for 1-10% of cases and usually has a self-limited course, without any risk of evolution toward constrictive pericarditis – which can cause signs of heart failure. But, it can result in pericardial effusions – up to 20% in some research studies. Most recommend that every case of pericarditis should get an echo to evaluate for pericardial effusion, and with good reason. In one study, fever of more than 100.4°F (38°C), subacute onset, immunosuppression, trauma, oral anticoagulation therapy, aspirin or nonsteroidal anti-inflammatory drug (NSAID) treatment failure, myopericarditis, severe pericardial effusion, and cardiac tamponade were designated as poor prognostic predictors. If there is a pericardial effusion, admit for serial echos and observation.