Patient Presentation
A 10-year-old male was brought by ambulance from his local doctor’s for worsening chest pain and suspected pericarditis or myocarditis. He had a 3 day history of mild cough, rhinorrhea and fever. On the day of admission his fever spiked to 103.8°F and he started to complain of left sided chest pain that was worsening. His mother said the cough was getting slightly worse and he seemed more tired but more agitated at the same time. He refused to lie down and asked to go to the doctor. The local physician heard a pericardial rub and referred him to the emergency department. The past medical history was normal. The family history had no significant cardiac history.
The pertinent physical exam showed a wide-eyed school ager, who was sitting up on the gurney. His blood pressure was 124/78, pulse of 118, respiratory rate of 32 with an oxygen saturation of 98%. He endorsed chest pain in the precordial area without radiation. Capillary refill was brisk. His HEENT showed mild pharyngitis and rhinorrhea. His cardiac examination showed no obvious murmur with a normal S1 and S2. He had a pericardial friction rub but no jugulovenous distension or hepatomegaly. Peripheral pulses were brisk.
The diagnosis of presumed pericarditis was made. The radiologic evaluation of a chest radiograph showed no cardiac silhouette enlargement. His electrocardiogram had mild ST segment elevation changes. His cardiac enzymes were normal. A cardiologist was consulted who also performed an echocardiogram which showed mild pericardial effusion and normal cardiac structures, movement and ejection fractions. She agreed with the diagnosis and the patient was admitted. He was monitored closely and his fever curve slowly decreased over the next 4 days. He slowly also started to feel better and was discharged on day 6. The laboratory evaluation was positive for adenovirus.
Discussion
The pericardium is a bi-layered membrane that envelops the heart and provides a barrier to prevent disease and also decreases friction as the heart moves. Pericarditis is the inflammation of pericardium. The incidence is underreported as asymptomatic or mild disease may go unrecognized. From hospitalized patient data, 0.2-5% of patients with various cardiac disease had pericarditis. An incidence rate for hospitalizations of 3.32 per 100,000 person years has been cited. Percarditis occurs more often in adolescent males.
Treatment of the underlying cause or suspected cause is important, along with close monitoring for worsening effusion and/or other worsening physical examination signs. Nonsteroidal anti-inflammatory medications are helpful to decrease pain and to reduce inflammation. Colchicine is used for recurrent pericarditis which can occur in up to 10% of patients. Steroid therapy is used usually when there is an underlying systemic inflammatory disease. Other options include azothioprine, anakinra or intravenous immunoglobulins.
In the developed world viral etiology or presumed viral etiology are 80-90% of cases. Worldwide tuberculosis is the most common cause and is associated with a high incidence of co-infection with human immunodeficiency virus. Viruses, bacteria, fungi, protozoa, autoimmune, neoplastic, metabolic and drugs can cause pericarditis. In the developed world the causes of pericarditis are similar to myocarditis which can be reviewed here. Prognosis is good with resolution for most patients especially with viral etiology. Bacterial pericarditis has a worse prognosis.
Learning Point
Typically pericarditis presents with pleuritic chest pain that is improved with sitting up and leaning forward and high fever. The chest pain is worsened with cough, movement and even just breathing. Patients with pericarditis often will resist lying down. On auscultation of the heart, classically a frictional rub is heard throughout the cardiac cycle. Large effusions may not have a rub and often have distant heart sounds. Signs of pericardial tamponade include jugular venous distension, hepatomegaly and poor peripheral perfusion.
A chest radiograph is usually obtained as it is often available and typically shows an enlarged cardiac silhouette and potentially increased pulmonary vascular markings. The cardiac silhouette can be normal though also. Electrocardiograms are also often available and classically show ST-segment elevation and low voltage QRS complexes. Echocardiograms, if available, can show the actual effusion and its size, and also help determine if there is associated myocarditis as well (20-30% of patients have both).
“Acute pericarditis is diagnosed based up on the presence of two of the following: chest pain that is consistent with pericarditis, pericardial friction rub, suggestive changes on [electrocardiogram], and new or worsening pericardial effusion.”
Questions for Further Discussion
1. How is myocarditis different than pericarditis? A review can be found here
2. How are pericardial and pleural effusions similar and different?
3. What is in the differential diagnosis of chest pain? A review can be found here
Related Cases
- Disease: Pericardial Disorders
- Symptom/Presentation: Chest Pain | Fever and Fever of Unknown Origin
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Pericardial Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA. 2015;314(14):1498-1506. doi:10.1001/jama.2015.12763
Leong K, Kane JM, Joy BF. Acquired Cardiac Disease in the Pediatric Intensive Care Unit. Pediatr Ann. 2018;47(7):e280-e285. doi:10.3928/19382359-20180620-01
Tunuguntla H, Jeewa A, Denfield SW. Acute Myocarditis and Pericarditis in Children. Pediatr Rev. 2019;40(1):14-25. doi:10.1542/pir.2018-0044
Areias JC. Pericarditis: Characteristics of a pediatric population. Rev Port Cardiol. 2019;38(2):103-104. doi:10.1016/j.repc.2019.02.003
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 