Acute Pericarditis 101: Self-Treatment Leads to Mistreatment
A 62-year-old male physician with a history of well-controlled gastroesophageal reflux disease and hypothyroidism presents for evaluation of recurrent, pleuritic chest pain that was worse with deep inspiration and lying flat. He first presented to his primary care provider months ago with dyspnea, fevers and fatigue. Electrocardiogram showed diffuse ST segment elevations and PR depressions (Figure 1). On physical exam, his BP was 122/75, heart rate of 70 beats per minute, temperature of 37.1°C, respiratory rate of 14 per minute, and oxygen saturation of 97% on room air. His jugular venous pressure was not elevated at 45 degrees. Cardiac exam revealed a normal S1 and S2 with no additional heart sounds and did not reveal a pericardial rub. Erythrocyte sedimentation rate was 38 mm/hr and C-reactive protein was 5.2 mg/L. Echocardiogram at the time showed a small circumferential pericardial effusion without signs of tamponade (Figure 2). The patient diagnosed himself with acute pericarditis and began treatment with oral prednisone 40 mg daily. Over the past several months he has tried several quick tapers off of prednisone without complete resolution of his symptoms and started on colchicine two months ago.
Figure 1: Rhythm strip showing diffuse ST-elevations and PR depressions with PR elevation and ST-depression in a lead aVR.
Figure 2: Transthoracic echocardiogram: apical four chamber view showing a small, circumferential pericardial effusion.
Which of the following is the patient's diagnosis and most appropriate treatment strategy?