Posters
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Resident
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Internal Medicine
Academic Level (Author 2)
Resident
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Internal Medicine
Academic Level (Author 3)
Faculty
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Internal Medicine
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Patient Care
Abstract
Background: Acute pericarditis is a rapid inflammatory condition of the pericardium with both infectious and non-infectious etiologies. Diagnosis is usually based on clinical criteria with typical symptoms including chest pain that worsens with deep inspiration and decreases by leaning forward, and distinctive electrocardiographic changes. Pericarditis is typically self-limiting however, complications like pericardial effusion and cardiac tamponade may arise.
Case presentation: A 31-year-old male presented to the emergency department due to severe epigastric pain radiating to the right upper abdomen; the pain was associated with subjective fever and inability to eat due to its severity. His physical exam revealed tachycardia and tenderness to palpation to the epigastric area with pain aggravated by deep inspiration. The patient was admitted with severe gastritis and concern for acute peptic ulcer disease versus cholecystitis, however, an abdominal ultrasound and CT were negative for gastrointestinal findings yet demonstrated a large pericardial effusion. A transthoracic echocardiogram confirmed the pericardial effusion and revealed tamponade physiology. Also, EKG exhibited moderate T-wave abnormalities. CRP and ESR were reported elevated and a viral panel was positive for Influenza B, CMV IgG, Coxsackie A7,9,16,24, B6 antibodies, and HSV 1 IgG. The patient was started on colchicine, ibuprofen, and oseltamivir, and underwent a pericardial window with a biopsy positive for fibrinous pericarditis. The patient was discharged home on NSAIDS and colchicine.
Conclusions: Acute pericarditis is the most common disorder involving the pericardium. In several settings, it may be either the first manifestation of an underlying systemic disease or represent an isolated process. In developed countries, most cases are viral in origin. Diagnosis requires at least 2 clinical features of pleuritic chest pain, pericardial rub, widespread ST elevations or PR depressions, or a new or worsening pericardial effusion.
Viral serology is typically not recommended as it does not change the management. Management for idiopathic and viral pericarditis includes NSAIDs and adjunctive colchicine for alleviation of symptoms and reduction of rates of recurrence. Corticosteroids are a second-line therapy for those with non-response, intolerance, or contraindications. Rilonacept is used for the treatment of recurrent pericarditis.
The presentation of the patient discussed in this case was remarkable since his presentation was concerning for either gastritis, peptic ulcer disease, or gallbladder disease. The initial imaging was key for broadening the differentials, unmasking the pericarditis, and recognizing the cardiac tamponade. Due to the urgency of the situation, early suspicion of tamponade may prevent hemodynamic decline. Thus, rapid imaging modalities, such as point-of-care ultrasound (POCUS), may prove an invaluable tool for evaluation. Additionally, clinicians should broaden their differential diagnosis and be aware of heuristic biases, particularly when there is a tendency for early closure or anchoring while evaluating pain in the emergency department.
Presentation Type
Poster
Recommended Citation
Torres Perez, Maria Eugenia; Capellan, Joan Beatrice; and Yamamura, Deanna, "Viral Party Gone Wrong: Polyviral Pericarditis Masquerading as Gastritis" (2024). Research Colloquium. 93.
https://scholarworks.utrgv.edu/colloquium/2024/posters/93
Included in
Viral Party Gone Wrong: Polyviral Pericarditis Masquerading as Gastritis
Background: Acute pericarditis is a rapid inflammatory condition of the pericardium with both infectious and non-infectious etiologies. Diagnosis is usually based on clinical criteria with typical symptoms including chest pain that worsens with deep inspiration and decreases by leaning forward, and distinctive electrocardiographic changes. Pericarditis is typically self-limiting however, complications like pericardial effusion and cardiac tamponade may arise.
Case presentation: A 31-year-old male presented to the emergency department due to severe epigastric pain radiating to the right upper abdomen; the pain was associated with subjective fever and inability to eat due to its severity. His physical exam revealed tachycardia and tenderness to palpation to the epigastric area with pain aggravated by deep inspiration. The patient was admitted with severe gastritis and concern for acute peptic ulcer disease versus cholecystitis, however, an abdominal ultrasound and CT were negative for gastrointestinal findings yet demonstrated a large pericardial effusion. A transthoracic echocardiogram confirmed the pericardial effusion and revealed tamponade physiology. Also, EKG exhibited moderate T-wave abnormalities. CRP and ESR were reported elevated and a viral panel was positive for Influenza B, CMV IgG, Coxsackie A7,9,16,24, B6 antibodies, and HSV 1 IgG. The patient was started on colchicine, ibuprofen, and oseltamivir, and underwent a pericardial window with a biopsy positive for fibrinous pericarditis. The patient was discharged home on NSAIDS and colchicine.
Conclusions: Acute pericarditis is the most common disorder involving the pericardium. In several settings, it may be either the first manifestation of an underlying systemic disease or represent an isolated process. In developed countries, most cases are viral in origin. Diagnosis requires at least 2 clinical features of pleuritic chest pain, pericardial rub, widespread ST elevations or PR depressions, or a new or worsening pericardial effusion.
Viral serology is typically not recommended as it does not change the management. Management for idiopathic and viral pericarditis includes NSAIDs and adjunctive colchicine for alleviation of symptoms and reduction of rates of recurrence. Corticosteroids are a second-line therapy for those with non-response, intolerance, or contraindications. Rilonacept is used for the treatment of recurrent pericarditis.
The presentation of the patient discussed in this case was remarkable since his presentation was concerning for either gastritis, peptic ulcer disease, or gallbladder disease. The initial imaging was key for broadening the differentials, unmasking the pericarditis, and recognizing the cardiac tamponade. Due to the urgency of the situation, early suspicion of tamponade may prevent hemodynamic decline. Thus, rapid imaging modalities, such as point-of-care ultrasound (POCUS), may prove an invaluable tool for evaluation. Additionally, clinicians should broaden their differential diagnosis and be aware of heuristic biases, particularly when there is a tendency for early closure or anchoring while evaluating pain in the emergency department.