Recurrent Pericarditis: When It Won't Go Away

Jul 23, 2019   |  Johnny Chahine, MD; Anirudh Kumar, MD, FACC; Chandra Kanth Ala, MD , FACC; James L Gentry, III, MD , FACC; Allan L. Klein, MD, CM, FACC
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A 56-year-old male with a past medical history of hypertension (on amlodipine 10 mg daily, hydrochlorothiazide 25 mg daily and lisinopril 40 mg daily), paroxysmal atrial fibrillation (not on anticoagulation), gastroesophageal reflux disease and benign prostatic hypertrophy, presented to the emergency room for chest pain and decreased exercise tolerance of 7 days duration.

Ten days ago, the patient developed flu-like symptoms. He was started on amoxicillin and clavulanate for concern for a bacterial upper respiratory infection. His respiratory symptoms resolved in about 3 days; however, he began developing pleuritic chest pain relieved on bending forward associated with shortness of breath at exertion. He also had bouts of self-resolving atrial fibrillation with a rapid ventricular response. Colchicine and aspirin 325 mg twice daily were started; however, his symptoms worsened. An echocardiogram was done as an outpatient for suspicion for acute pericarditis and showed a large circumferential pericardial effusion without evidence of constrictive physiology or tamponade. He was then started on oral methylprednisolone and referred to the emergency department.

The patient was in his usual state of health until 4 months ago, when he presented to the emergency room with similar chest pain. He underwent a computed tomography angiography of his chest, which was negative for pulmonary embolism or any acute pulmonary process. Echocardiography revealed small circumferential pericardial effusion. He was diagnosed with acute pericarditis and discharged on 4 days of colchicine 0.4 mg three times daily, and he became symptom-free in a few days. He also had a stress test completed after the initial episode, and it was negative.

On arrival, his temperature was 36.3 degrees Celsius, pulse was 64 beats per minute, respiratory rate was 14 breaths per minute, blood pressure was 147/88 mm Hg, and oxygen saturation was 98% on room air. His physical exam showed a jugular venous pressure of 15 cm water, and regular S1 and S2 and was negative for a pericardial rub, Kussmaul's sign, pulsus paradoxus or lower limb edema.

His laboratory workup showed an erythrocyte sedimentation rate of 29 mm/hour (normal range: 0 - 20 mm/hour), a C-reactive protein of 2.7 mg/dl (normal range: less than 0.9 mg/dl), NT-proBNP of 296 (normal range: less than 125 pg/ml), normal kidney function, negative cardiac enzymes, hemoglobin of 15.3 g/dl (normal range: 11.5 - 15.5 g/dl), platelets of 266 k/uL (normal range: 150-400 k/ul), Coxsackie B type 4 titer of 1:320 (normal range: less than 1:10), normal autoimmune workup, negative HIV, and negative tuberculosis. His electrocardiogram showed normal sinus rhythm with no electrical alternans, PR depression or ST elevation. Chest X-ray revealed an enlargement of the cardiac silhouette (Figure 1). A transthoracic echocardiogram showed a large circumferential pericardial effusion measuring 2.6 cm. There was no diastolic chamber collapse; however, the inferior vena cava measured 2.4 cm and decreased less than 50% with inspiration, and the respiratory inflow variations across the tricuspid and mitral valves were 41% and 13.7% respectively (Figure 2). Cardiac MRI done showed pericardial delayed enhancement on fat-suppressed sequences without constrictive physiology (Figure 3). The patient was started on colchicine 0.6 mg twice daily, aspirin 650 mg twice daily and prednisone 30 mg daily and had pericardiocentesis the next day with 430 ml of bloody fluid drained. Pericardial fluid analysis and cultures were negative for tuberculosis, fungal or bacterial infections. His symptoms improved and he was discharged on colchicine 0.6 mg twice daily, aspirin 650 mg twice daily, prednisone 30 mg once daily and was advised to restrict exercising.

Figure 1

Figure 1
Figure 1: Chest X ray showing enlargement of the heart silhouette (black arrow).

Figure 2

Figure 2
Figure 2: Transthoracic echocardiography, parasternal short axis view, showing circumferential pericardial effusion (red double arrows).

Figure 3

Figure 3
Figure 3: Cardiac MRI phase sensitive inversion recovery fat suppressed sequence showing delayed pericardial enhancement (orange arrow) with a large size pericardial effusion (red arrow).

Which of the following has most likely increased the risk of recurrence of this patient's viral pericarditis?

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