1) Which clinical presentations of the patient suggest diagnosis of Acute Pericarditis?
The patient had a chest pain that became worse when she lied supine and a friction rub was heard on physical examination. ESR and CRP levels were elevated. The characteristic ECG changes are ST elevations and PR depressions in several leads.
2) What's the common etiologies for Acute Pericarditis?
In most case series, the majority of patients are not found to have an identifiable cause of pericardial disease. Frequently such cases are presumed to have a viral or autoimmune etiology.
3) In your opinion which of these is the main cause of pericarditis in this patient?
Acute salmonella pericarditis is a quite rare finding. In this case, pericarditis could be related to this prior infection or more probably an immune reaction to salmonellosis.
4) What are the important differential diagnoses for the patient?
All other causes of chest pain may be considered in the differential diagnosis of pericarditis, but acute extensive myocardial infarction is the most important, because both conditions present with chest pain and ST-elevation on several leads on the electrocardiogram.
An extensive MI should be suspected when reciprocal changes (ST depression) are seen on some of the other leads on ECG. The patient would also be expected to present with cardiogenic shock in the case of a global MI (ST elevation on all leads).
The course of ST-T changes also help in the differential diagnosis: T-wave inversions are usually seen within hours before the ST segments have become isoelectric in AMI, but the T waves become inverted after the ST segments return to normal in pericarditis.
5) What risk factors suggest you to admmit a patient with the similar setting?
Some physicians admit all new cases of acute pericarditis to the hospital, but this may not be necessary. Others prefer to hospitalize high risk patients: Fever (>38ºC) and leukocytosis, evidence suggesting cardiac tamponade, a large pericardial effusion (ie, an echo-free space of more than 20 mm), immunosuppressed state, a history of oral anticoagulant therapy, acute trauma, failure to respond within seven days to NSAID therapy and elevated cardiac troponin (suggestive of myopericarditis).
6) What signs or symptoms may suggest the probability of Tamponade?
Sinus tachycardia, elevated jugular venous pressure and pulsus paradoxus.
7) What's the recommended treatment for acute pericarditis?
NSAIDs are recommended for all patients without a contraindication.
Colchicine may be added as an adjunct to NSAID therapy to reduce the rate of recurrent pericarditis (not routinely).
The use of glucocorticoids should be restricted to patients with: acute pericarditis due to connective tissue disease, autoreactive (immune-mediated) pericarditis and Uremic pericarditis.
8) What findings of an ECG suggest acute pericarditis? Please interpret the ECG of the patient.
Widespread elevation of the ST segments involving two or three standard limb leads and V2 to V6, with reciprocal depressions only in aVR and sometimes V1, as well as PR-segment depression.
ECG of the patient:
Sinus tachycardia (not NSR), rate=115, normal axis, no AV block (normal PR interval), no IVCD (normal QRS duration), PR depression and ST elevation on almost all leads (except aVR).