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Acute Pericarditis : A case report

Author : I.R. Hidayat, A. P. Ayu, T. T. Dewi, I. Rakhmawati, D. Y. Pertiwi, D. Rostiati
Upload Date : 19-04-2018

Introduction: Pericarditis indicates inflammation of the pericardium due to various causes. The incidence of acute pericarditis is difficult to quantify because there are undoubtedly many undiagnosed cases. Pericarditis is diagnosed in 0.1% of hospitalized patients and in 5% of patients seen in emergency room with chest pain but without myocardial infarction. In 80-90% of patients, the cause is either viral or unknown (idiopathic). Idiopathic pericarditis is thougt to be very common because the yield of diagnostic tests to confirm aetiology is relatively low. The major specific cause to be ruled out are tuberculous pericarditis, metastatic neoplasia, and connective tissue disorders.

Objective: To present a case report of a patient with chest pain due to acute pericarditis.

Case Ilustration: A 42-year-old man came to the emergency room with complaints of chest pain complaint. Patients present with chest pain on the left side since 1 week ago. Chest pain complaints arise suddenly. Complaint accompanied by a sudden high fever. He was post-hospitalized for 6 days in AMC Hospital, was allowed to go home 1 day, but the complaint of chest pain arise again and not disappear. He admitted that his chest pain complaints have not fully improved.

Chest pain as sharp prickling sensation and feeling like crushed heavy objects. This complaint is accompanied by difficulty of breathing because the pain increases as he takes a deep breath. This complaint was accompanied by a high fever and he had fainted for several minutes. He is also more comfortable in sitting up and leaning forward, because the pain is less than when lying down.

He was a heavy smoker since about 20 years ago. In a day he can spend 3 packs of cigarettes. He also has a long history of cough that is already more than two years back, intermittent. The history of tuberculosis is denied.

On examination found blood pressure 100/60 mmHg, pulse 110 x/m, respiratory rate 30x/m, temperature 39,5 0C. Physical examination found: alert, awake and oriented. well developed and well nourished. Neck, no jugular venous distention. Cardiovascular, regular rate rhytm, S1 and S2 are normal, pericardial friction rub, no murmur, no gallops. Lungs clear to auscultation.

ECG was found ST segment elevation in leads I, II, III, aVF, v6 and PR segment depression in lead II, lead III and AvF, and reciprocal ST segment depression in aVR. ECG data from previous hospitalization care: ST elevation in leads I, II, aVF, v3, v4, v5, v6 and PR segment depression in lead II, and reciprocal ST segment depression in aVR and v1.

Laboratory tests performed obtained: HGB 9,9 gr/dL ,WBC :17.470 uL, HCT 28%, PLT: 484.000 uL, AST 38 U/L, ALT 52 U/L, Creatinin 0,97 mg%, CKMB 6,9.  Microbiology test for BTA sputum found negative.

Chest X-Ray photo found no cardiomegaly and suggestive of pulmonary tuberculosis.

Echocardiography showed good cardiac function, adequate systolic function, EF 59% , normokinetic at rest, accompanied by mild pericardial effusion.

Treatment of inpatient care in previous hospital are aspilet 1x1 ,isdn 3x1, cpg 1x1, atorvastatin 1x10 mg, furosemide 1x40 mg, ksr 1x1. He was given NSAID treatment ibuprofen 2x200 mg, intravenous antibiotic injection, inj. Ranitidin 2x1 amp iv , and inj. MP 2x62,5 mg iv. Then the patient was discharged after 7 days treatment at the hospital. Unfortunately the patient did not come again for a routine checkup. (patient out of control)

Discussion: Acute pericarditis, defined as symptoms or signs resulting from pericardial inflammation of no more than 1 to 2 weeks in duration, majority of cases are idiopathic. Most cases of acute idiopathic pericarditis are presumed to be viral in etiology, but testing for specific viruses is not routine because of cost and the fact that this knowledge rarely alters management.

In this case, patient came with chest pain sudden in onset, typically accentuated by inspiration and attenuated by sitting up and leaning forward. On vital sign showed body temperature 39,5 0C, and there is leukocytosis on laboratory studies (WBC: 17.470) this may indicate purulent pericarditis. There is no evidence of tuberculosis infection and uremic state.

 ECG can be diagnostic in acute pericarditis and typically shows diffuse ST elevation and PR segment depression. To differentiate with MI (Myocardial Infarction), in MI ST segment elevation usually regional rather than widespread. Also in MI there are Q wave formation and loss of R wave voltage often occur. And PR segment depression is uncommon in MI.

Echocardiography found normal with mild pericardial effusion.

Treatment is directed to resolving symptoms. In this case Ibuprofen is preferred for its fewest side effects along with gastro-protection drug ranitidine. Antibiotic iv also being administered because of the evidence of bacterial infection.

Colchicine (0,5 mg bid) added to an NSAID or as mono-therapy is also effective and has been shown to prevent recurrences.

Systemic steroid therapy is restricted to patients with symptoms refractory to standard therapy or to other forms of non-idiopathic pericarditis such as uremic pericarditis or pericarditis secondary to connective tissue diseases. In this case, systemic steroid were given due to the poor response to aspirin therapy and he was severely symptomatic.

Conclusion: Prognosis of acute pericarditis depends on etiology and comorbidities. Conditions such malignancy, uremia, and HIV have the worse prognosis. Viral or idiopathic pericarditis is usually a benign condition with very low mortality.

KEYWORDS : Acute pericarditis, Pericardial effusion, PR segment depression, ST elevation

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