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What's the Diagnosis?

November 2019

Visual Diagnosis

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Author: Joe Julian, MD, MPHTM | Hospitalist, Internal Medicine, Pediatrics | Assistant Professor, UMKC School of Medicine 

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Column Editor: Angela Myers, MD | Director, Division of Infectious Diseases | Associate Director, Infectious Diseases Fellowship Program | Associate Professor of Pediatrics, UMKC School of Medicine 

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A 17-year-old female is directly admitted for further evaluation of chest pain. Symptoms started with two days of diarrhea and vomiting, followed by one day of chest pain that is located centrally with radiation up to neck and worsens when lying flat. The pain improves with leaning forward. She had associated fevers up to 102°F yesterday and earlier today. Family history is negative for cardiac disease and she denies illicit drug use. Vital signs are within normal limits. Cardiac examination is notable for regular rate and rhythm, no murmurs/rubs, and a normal S1/S2. There is no jugular venous distension or pitting edema. Troponin I is elevated at 14.4 (reference range <0.07) and her EKG is shown. Echocardiogram is obtained, which does not show any pericardial effusion or wall motion abnormalities.

Which of the following is the best treatment option for this patient? 
 
A.  Ibuprofen and colchicine                   
B.  Aspirin, atorvastatin and metoprolol       
C.  High-dose prednisone with taper           
D.  Cardiac catheterization with stent placement       

A.  Ibuprofen and colchicine

This patient is presenting with chest pain in the setting of regional ST-elevations and an elevated troponin, which is concerning for a myocardial infarction. Her EKG is notable for ST elevation of ≥ 1mm in II, aVF, V6 (III is very poor quality and V5 with 0.5mm ST elevation) with ST depressions in V1-2. However, there are several components of the EKG that support a non-ischemic etiology.

The ST elevations here are concave in nature. In myocardial infarctions, convex-shaped ST segments (“tombstones”) are much more commonly seen. Next, there are incomplete reciprocal changes (ST depressions should be seen in I and aVL if there is concern for inferior distribution). Third, the patient does not have any risk factors (family history of premature cardiac disease, illicit drug use, etc.) that would make her at higher risk for a cardiac event.

This patient has myopericarditis. Focal EKG changes are well documented in the literature for this condition. The typical EKG progression in pericarditis may not be seen if there is significant myocardial involvement. The elevated troponin is not associated with adverse outcomes and this disease is typically benign. The correct treatment is NSAIDs with colchicine to decrease the inflammation that is present. Cardiac catheterization is occasionally needed in cases that are unclear or that show focal wall motion abnormalities on echocardiogram.

References

  1. Acute Myopericarditis with Focal ECG Findings Mimicking Acute Myocardial Infarction. Nibet and Breyer. J Emerg Med. 2010; 39:153-158.
  2. Focal ST-Segment Elevation in a Young Man. Shak, Johnson, and Goldschlager. JAMA Intern Med. 2016; 176(9):1388-1389.
  3. Acute Myopericarditis in an Adolescent Mimicking Acute Myocardial Infarction. Sharma et al. Pediatr Emerg Care. 2015; 31(6):427-430.