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Dan Yang: Discussion

The development of chest pain following a viral illness should suggest pleural or pericardial inflammation. Anterior chest pain radiating to the trapezius ridge, made worse by lying supine, and relieved by leaning forward while seated is typical of pericarditis.

Cardiac auscultation may reveal a pericardial friction rub, although this finding is often intermittent or absent. Fever preceding chest pain is typical of acute pericarditis whereas fever usually follows the onset of chest pain in the pericarditis resulting from myocardial infarction.

The EKG shows sinus rhythm, normal axis, normal QRS complexes, and widespread ST elevation, especially in leads 2, 3, AVF, and V3-6. The T waves are upright except for AVR in which the T wave is normally inverted.

Possible causes of ST elevation include acute myocardial infarction, transmural coronary ischemia, as in variant or Printzmetal's angina, pericarditis, ventricular aneurysm, and early repolarization or high take-off (a normal variant in young adults). In pericarditis the ST elevation often involves both anterior and inferior surfaces and the T waves remain upright for the first 1-2 days, inverting slowly thereafter. In myocardial infarction ST elevation is usually primarily anterior or inferior and T waves invert quickly, within minutes to hours.

The Chest x-ray is normal. Pericarditis can sometimes be accompanied by pleural effusions or pulmonary infiltrates resulting from viral pleurisy or pneumonitis.

The laboratory test results show lymphocytosis consistent with a viral illness, helping to rule out a bacterial infection. The chemistries are normal and help to rule out significant dehydration from the preceding diarrheal illness.

Acute pericarditis in younger individuals is usually caused by an enteric or respiratory virus and is associated with a fibrinous exudate without a significant effusion or risk of tamponade. However tamponade can occur. There are many other possible causes of pericarditis, including collagen vascular disease, malignancy, radiation therapy, and myocardial infarction, all of which are more common with advancing age.

Additional tests could include an echocardiogram to rule-out a large pericardial effusion and an ANA as a screen for lupus.

Treatment with an ANSAID such as ibuprofen 600 mg p.o. q.i.d. often results in prompt resolution of symptoms. A narcotic analgesic such as meperidine 50 mg q 4 hours may help to relieve pain over the first several days.

Patients with persistent or recurrent symptoms will need further evaluation and treatment, sometimes with corticosteroids or surgical stripping of the pericardium.

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