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Case 006: Adolescent Chest Pain - Pericarditis

Presentation

A 16-year-old male presents with 2 days of sharp chest pain. Pain is worse when lying flat and improves when sitting forward. He had a viral URI 1 week ago.

Vital Signs: - Heart rate: 98 bpm - Blood pressure: 118/72 mmHg - Respiratory rate: 18 - SpO2: 99% on room air - Temperature: 37.8°C

Exam: - Alert, uncomfortable, leaning forward - 3-component pericardial friction rub at left sternal border - Clear lungs - No lower extremity edema

Initial Workup

ECG: - Diffuse ST elevation with concave upward morphology - PR depression - No reciprocal changes

Labs: - Troponin I: 0.15 ng/mL (mildly elevated) - CRP: 8.5 mg/dL - WBC: 11,200 - BMP: Normal

Echocardiogram: - Small circumferential pericardial effusion (0.5 cm) - Normal LV function - No tamponade physiology

Chest X-ray: Normal cardiac silhouette

Clinical Reasoning

Question 1: What is the diagnosis?

Answer **Acute pericarditis** with likely myopericarditis (elevated troponin) Meets ≥2 of 4 diagnostic criteria: 1. ✓ Chest pain (pleuritic, positional) 2. ✓ Pericardial friction rub 3. ✓ ECG changes (diffuse ST elevation, PR depression) 4. ✓ Pericardial effusion (on echo) Elevated troponin suggests myocardial involvement (myopericarditis).

Question 2: What causes pericarditis in adolescents?

Answer **Most common: Viral/Idiopathic** (~80-90%) Viral causes: - Coxsackie B, Echovirus - Adenovirus, Parvovirus B19 - EBV, CMV, Influenza Other causes to consider: - Autoimmune (SLE, JIA) - Post-cardiac surgery (PCIS) - Bacterial (rare, more severe) - TB (endemic areas) - Drug-induced - Malignancy

Question 3: Does the small effusion change management?

Answer **No immediate concern** - small effusion without tamponade **Watch for tamponade signs:** - Beck's triad (hypotension, JVD, muffled heart sounds) - Pulsus paradoxus (>10 mmHg) - Echo findings: RA/RV diastolic collapse, IVC plethora This effusion is small and hemodynamically insignificant.

Management

Question 4: What is the first-line treatment?

Answer **Triple therapy for acute pericarditis:** 1. **NSAIDs** - first-line anti-inflammatory - Ibuprofen 600mg TID or naproxen 500mg BID - Continue until symptoms resolve + CRP normalizes 2. **Colchicine** - REDUCES RECURRENCE (key benefit!) - 0.5mg BID (weight-based in children) - Continue for 3 months - Evidence: COPE, CORE trials showed ~50% reduction in recurrence 3. **Activity restriction** - No exercise until symptoms resolve, CRP normal, echo normal - Typically 2-4 weeks minimum

Question 5: When are corticosteroids indicated?

Answer **Corticosteroids are NOT first-line** - actually INCREASE recurrence risk Indications for steroids: - NSAID contraindication (renal failure, GI bleed) - Incomplete response to NSAIDs + colchicine - Autoimmune/inflammatory cause - Pregnancy If used, use LOW dose and SLOW taper (over months, not weeks).

Question 6: What about the elevated troponin?

Answer **Myopericarditis** - requires additional precautions Management adjustments: - Longer activity restriction (minimum 3-6 months) - May need repeat echo/CMR to assess for myocardial involvement - Follow troponin to normalization Does NOT change NSAID + colchicine therapy. CMR useful for: - Confirming myocardial involvement - Assessing extent - Prognostication

Follow-up

At 2-week follow-up: - Pain resolved - CRP: 0.8 mg/dL (normalized) - Repeat echo: Effusion resolved

Question 7: When can he return to sports?

Answer **Return to play criteria for myopericarditis:** 1. Asymptomatic 2. CRP normalized 3. Echo normalized (no effusion, normal function) 4. ≥3-6 months from diagnosis (myopericarditis requires longer restriction) 5. No arrhythmias on Holter (if concern) For uncomplicated pericarditis without troponin elevation: 2-4 weeks may be sufficient.

Teaching Points

  1. Pericarditis diagnosis: ≥2 of 4 criteria (pain, rub, ECG, effusion)
  2. Colchicine reduces recurrence - give for 3 months
  3. Avoid steroids first-line - increase recurrence risk
  4. Elevated troponin = myopericarditis - longer activity restriction
  5. ~30% recurrence rate without colchicine; ~15% with colchicine