Case Quiz: Positional Chest Pain in a 42-year-old Man

Patient history. A 42-year-old man presents to the ED complaining of ~24h of pleuritic LEFT-sided chest pain that is worse when he lies flat; denies fever, cough but had URI 1 month ago; describes rib pain on the RIGHT ~ 3wks ago that was diagnosed as shingles w/o rash, treated with famciclovir, and resolved.
 

Vital signs and examination. Vital signs are normal, PE unremarkable. Differential diagnosis: pericarditis
pulmonary embolism, acute coronary syndrome.

Initial ECG. The computer read is NSR, left axis deviation. Do you agree? What is your diagnosis?

Computer ECG read is correct. The computer is quite good at determining the axis. Otherwise, no significant ECG abnormalities.

Results of testing. CXR findings are normal. D-dimer level was elevated, CT scan or chest ordered; no PE seen, but noted was a left lingular infiltrate and a small right pleural effusion.

Diagnosis/case conclustion. Initial troponin level was elevated but unchanged on repeat testing. Cardiology was consulted and diagnosed pericarditis secondary to an adjacent pneumonia. NB: pericarditis has a normal ECG in  ~30% of cases. Patient was admitted/treated for the pneumonia and the pericarditis resolved.

Pericarditis-presentation. Typically presents with pleuritic left-sided chest pain that is often worse when the patient is supine; pain may radiate to left shoulder or scapula area; physical exam is typically normal. Rub is rarely heard and when present may be transient. ECG during the initial period often shows subtle ST elevation that is diffuse along with PR depression.

Pericarditis--evaluation/differential. Echocardiography is the imaging test of choice for pericarditis; however, CT chest is often ordered to either rule out PE when d-dimer level is elevated, or to rule out aortic dissection. Troponins are typically normal, but when elevated signify concomitant myocarditis.

Pericarditis--treatment. Most cases of pericarditis are idiopathic and typically treated with colchicine, NSAIDs. Target therapy to cause, if determined. Cardiology should usually be involved, especially in recurrent or complicated cases. For more details on diagnosis, ECG findings, and causes of pericarditis see sample page on next slide.