23 yo With Chest Pain

Hx: A 23 yo male complains of chest pain. It has been present for 2 days, and intermittent. This morning he awoke feeling well but then developed 2/10 dull mid chest pressure, non-radiating, but associated with a tightness in his right arm. His right arm also felt weak to the point where he had difficulty holding a cup. No shorties of breath or back pain or neck pain. There has been a dull frontal sinus headache for the same duration, but no fever or cough. At time of presentation, the chest pain is mild but still present, as is the right arm discomfort.

PMHx: Anxiety

SocHx: No tobacco, occasional alcohol, no drugs.

Exam:

  • Vital Signs: BP 135/80, HR 85, RR 14, O2sat 98% room air, temp 98.6 F (37C)
  • General: mildly anxious, sitting up in stretcher
  • HEENT: normal
  • Res: clear to auscultation bilaterally
  • Heart: regular rate and rhythm. No murmurs.
  • Abdomen: soft, non-tender, no masses
  • Extremities: normal pulses, warm, normal tone
  • Neurological: normal cranial nerves, normal extremity strength and sensation, alert

Differential Diagnosis: 

  • Acute MI
  • Pericarditis
  • Aortic Dissection
  • Pulmonary Embolism
  • Esophageal Spasm
  • Anxiety/Panic Attack
  • Coronary Spasm
  • Coronary Dissection
  • Benign Early Repolarization

Diagnostics:

  • EKG #1- benign early depolarization changes, rate of 85
EKG1.jpg

EKG #1

  • Labs – normal except for a troponin I (point of care) = 5.93 (normal <0.08)
  • Chest xray – normal
  • ECG #2- continued J point elevation with more exaggerated ST elevation in lateral leads

    EKG2.jpg

    EKG #2

  • CT angiogram of the chest and abdomen to exclude dissection was normal

Hospital Course:

  • Given second EKG with worsening ST elevation in lateral leads, and markedly elevated troponin, the patient is taken to the cath lab emergently to exclude a structural cause (coronary dissection).
  • Coronary angiogram was normal, with EF noted to be 50%.
  • He is admitted and monitored with troponin I peaking at 15.9 then trending downward. However, he continues to have intermittent episodes of non-exertional chest pressure.
  • He is begun on an ACE inhibitor and a Beta-Blocker as well as daily aspirin.
  • Repeat Echocardiogram shows EF improves to 55%
  • Discharged home in good condition and placed on restrictions for light duty only, and follow up in 1 week to re-access the patient’s symptoms.

Diagnosis: Acute Myocarditis

Discussion:  

Myocarditis is a spectrum of disease. Symptoms can range from no chest discomfort up to full blown heart failure and cardiogenic shock. The typical range of patient age is 20-50 and the majority of cases are thought to be related to viral illness, even in the absence of specific viral antigen or antibody testing. Up to 50% of cases are labeled as idiopathic, but the list of other causes of myocarditis is extensive and may include : (see http://emedicine.medscape.com/article/156330-overview#a5)

  • Viral – Enterovirus, coxsackie B, adenovirus, influenza, cytomegalovirus, poliomyelitis, Epstein-Barr virus, HIV-1, viral hepatitis, mumps, rubeola, varicella, variola/vaccinia, arbovirus, respiratory syncytial virus, herpes simplex virus, yellow fever virus, rabies, parvovirus
  • Rickettsial – Scrub typhus, Rocky Mountain spotted fever, Q fever
  • Bacterial – Diphtheria, tuberculosis, streptococci, meningococci, brucellosis, clostridia, staphylococci, melioidosis, Mycoplasma pneumoniae, psittacosis
  • Spirochetal – Syphilis, leptospirosis/Weil disease, relapsing fever/Borrelia, Lyme disease
  • Fungal – Candidiasis, aspergillosis, cryptococcosis, histoplasmosis, actinomycosis, blastomycosis, coccidioidomycosis, mucormycosis
  • Protozoal – Chagas disease, toxoplasmosis, trypanosomiasis, malaria, leishmaniasis, balantidiasis, sarcosporidiosis
  • Helminthic – Trichinosis, echinococcosis, schistosomiasis, heterophyiasis, cysticercosis, visceral larva migrans, filariasis
  • Bites/stings – Scorpion venom, snake venom, black widow spider venom, wasp venom, tick paralysis
  • Drugs (usually causing hypersensitivity myocarditis)
  • Chemotherapeutic drugs – Doxorubicin and anthracyclines, streptomycin, cyclophosphamide, interleukin-2, anti-HER-2 receptor antibody/Herceptin
  • Antibiotics – Penicillin, chloramphenicol, sulfonamides
  • Antihypertensive drugs – Methyldopa, spironolactone
  • Antiseizure drugs – Phenytoin, carbamazepine
  • Amphetamines, cocaine, catecholamines
  • Chemicals – Hydrocarbons, carbon monoxide, arsenic, lead, phosphorus, mercury, cobalt
  • Physical agents (radiation, heatstroke, hypothermia)
  • Acute rheumatic fever
  • Systemic inflammatory disease – Giant cell myocarditis, sarcoidosis, Kawasaki disease, Crohn disease, systemic lupus erythematosus, ulcerative colitis, Wegener granulomatosis, thyrotoxicosis, scleroderma, rheumatoid arthritis
  • Peripartum cardiomyopathy
  • Posttransplant cellular rejection

The diagnostic evaluation of myocarditis can be significant and include any of the following:

  • Labs and viral titles may be obtained.
  • Cardiac catheterization is performed to exclude obstructive disease or coronary dissection.
  • Cardiac MRI is performed to ascertain the location and extent of involvement based on myocardial edema.
  • Echocardiography is performed to exclude structural disease and perform ongoing measurements of ejection fraction.
  • Scintigraphy (antimyosin, gallium, PET scanning) may be utilized to determine the extent of inflammation as well.
  • Endomyocardial biopsy may be performed to obtain a tissue sample for pathology testing.

Treatment is aimed at supportive care. Immunosuppressive therapy is generally not recommended. Use of ace inhibitors and beta blockers is common. Anticoagulation with aspirin or other agents may be recommended depending on the results of imaging studies. Cardiac conduction abnormalities may require pacemaker placement. Severe cardiomyopathies may also require utilization of left ventricular assistive devices (LVAD). Finally, heart transplantation has bee shown to be of benefit in the most severe cases. In general, those with preserved ejection fraction have good outcomes with minimal (if any) residual symptoms.

For further reading:

Medscape

UpToDate (subscription required)

Disclaimer

De-identificaiton is undertaken utilizing the Safe Harbor method described by the US Department of Health and Human Services. All remaining patient information required for teaching purposes has been altered to maintain this standard.

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