17-Year-Old Male with Recurrent Chest Pain
A 17-year-old male with no past medical history presented to the emergency department (ED) with acute onset, sharp, substernal non-radiating chest pain. The pain was worse with deep inspiration but was not positional. The patient's younger brother suffered from hand, foot, and mouth disease three weeks prior to symptom onset.
Vital signs were normal (T 36.9C, BP 133/72mmHg, HR 93 bpm, RR 13/min, SpO2 99% on room air).
Physical exam did not reveal any murmurs, rubs or gallops and the estimated jugular venous pressure was normal without increase in inspiration.
His presenting ECG showed diffuse ST elevations and PR depressions (Figure 1).
Troponin T was 0.03 ng/dl and WBC 9.0 k/ul.
A transthoracic echocardiogram (TTE) showed a small circumferential pericardial effusion and normal left ventricular function.
The diagnosis of acute pericarditis was made and the patient was discharged on ibuprofen 600mg TID and colchicine 0.6mg BID.
One week later he presented again to the ED with worsening chest pain and dyspnea. At that time the TTE showed worsening pericardial effusion (Figure 2). The patient underwent pericardiocentesis which yielded 400ml of exudative fluid. Gram stain, cultures and cytology were negative.
The patient was discharged on ibuprofen 800mg TID, colchicine 0.6mg BID and prednisone 40mg daily for two weeks with the instruction to taper the dose by 10mg every week. His symptoms resolved quickly within a week and he returned back to his activities, including swimming and cross country running.
Shortly after the initiation of prednisone taper, the chest pain recurred, so the patient was referred to the Pericardial Clinic. At that time he reported pleuritic chest pain 3/10. Physical exam did not reveal any rubs, gallops, elevated JVP or Kussmaul sign. CRP was 6.3mg/dl (reference range 0.0-1.0mg/dl), ESR 21 mm/hr and Troponin T <0.01 ng/dl. A Cardiac MRI with gadolinium showed delayed gadolinium enhancement (Figure 3) as well as increased signal intensity on T2-STIR images (Figure 4).
Which of the following best describes the patient's condition based on the clinical course and imaging findings?