A 34-year-old woman is evaluated in the emergency department due to 1-day of chest and left shoulder pain. The patient describes the pain as constant and worse in certain positions. A month ago, she was treated for a skin rash and joint pain. Her medical history is otherwise unremarkable. She is a lifetime nonsmoker and does not use alcohol or illicit drugs. Her father has hypertension and had a stroke at age 64. Temperature is 37.5 C (99.5 F), blood pressure is 122/70 mm Hg, and pulse is 97/min and regular. A triphasic, scratchy sound is heard over the left sternal border with the patient sitting up. The lungs are clear on auscultation. ECG shows sinus rhythm with ST-segment elevation in all leads except avR and V1. Which of the following is the most likely diagnosis?
Acute pericarditis | |
Etiology |
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Clinical features |
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SLE = systemic lupus erythematosus. | |
This patient with pleuritic-type chest pain radiating to the shoulder and a recent history of skin rash and joint pain likely has acute fibrinous pericarditis due to systemic lupus erythematosus. Fibrinous pericarditis is the most common type of pericarditis and consists of pericardial inflammation with serous fluid and fibrin-containing exudate in the pericardial space.
Patients typically have pleuritic (sharp, worse with breathing or movement) anterior chest pain that can radiate to the left shoulder or posteriorly to the bilateral scapulae. Fibrin deposition causes roughening of the visceral and parietal pericardium, often heard as a triphasic friction rub (occurring during atrial systole, ventricular systole, and early ventricular diastole) on cardiac auscultation; however, the rub can be absent if significant pericardial effusion is present. ECG typically shows diffuse ST elevation due to inflammation of the ventricular myocardium.
Other causes of fibrinous pericarditis include viral infection, myocardial infarction, uremia, and other rheumatologic disease (eg, rheumatoid arthritis). If acute fibrinous pericarditis goes without treatment, chronic constrictive pericarditis can develop in some patients.
(Choice A) Eosinophilic myocarditis can occur with malignancy, parasitic infection, or drug hypersensitivity and often presents with symptoms of heart failure. A friction rub on cardiac auscultation is not expected.
(Choices C and E) Hemorrhagic and purulent pericarditis are both less common than fibrinous pericarditis. Hemorrhagic pericarditis consists of blood mixed with fibrinous exudate; it most commonly occurs in the setting of malignancy but may also occur due to tuberculosis, following cardiac surgery, or in patients with underlying coagulopathy. Purulent pericarditis results from active bacterial infection (eg, Staphylococcus aureus, Streptococcus species) in the pericardial space, which may occur due to hematogenous spread or direct extension of pneumonia or endocarditis.
(Choice D) Nonbacterial endocarditis can occur in systemic lupus erythematosus and involves deposition of sterile, platelet-rich thrombi on the mitral or aortic valve. It would not explain a friction rub or diffuse ST elevation on ECG.
Educational objective:
Fibrinous pericarditis is the most common type of pericarditis and is characterized by pericardial inflammation with a serous, fibrin-containing exudate in the pericardial space. Pleuritic chest pain and a triphasic friction rub are frequently seen. Common causes include viral infection, myocardial infarction, uremia, and rheumatologic disease (eg, systemic lupus erythematosus, rheumatoid arthritis).