Regional Pericarditis: an unusual diagnosis Nitin Gupta DO, Juan - - PowerPoint PPT Presentation
Regional Pericarditis: an unusual diagnosis Nitin Gupta DO, Juan Pablo Rodriguez-Escudero MD, Rehan Ansari MD, Roger Chaffee MD, Otto Costantini MD Overview Review Case Differential Diagnosis Disease Pathogenesis Patient Update
Nitin Gupta DO, Juan Pablo Rodriguez-Escudero MD, Rehan Ansari MD, Roger Chaffee MD, Otto Costantini MD
▪ Review Case ▪ Differential Diagnosis ▪ Disease Pathogenesis ▪ Patient Update
74 yo CM presents to ED with left sided chest pain. Started 45 minutes after trimming rose bushes. Pleuritic in nature, radiating across chest, associated with SOB. Took ASA. Pain eased to dull sensation with nitro.
▪ PMHx: OSA (compliant with CPAP), HLD, RLS ▪ PSHx: R Knee arthroplasty 3/2017, Lumbar fusion 1/2018 ▪ FamHx: n/a ▪ Social Hx: Former Smoker (quit in 1974), social drinker (once every couple of months), denies illicit drugs
▪ Vitals: BP 133/78 | Pulse 72 | Temp 97.8 °F (36.6 °C) (Oral) | Resp 18 | SpO2 97% ▪ General appearance: alert, appears stated age and cooperative ▪ Skin: Skin color, texture, turgor normal. No rashes or lesions ▪ HEENT: Head: Normocephalic, no lesions, without obvious abnormality. ▪ Neck: no adenopathy, no carotid bruit, no JVD, supple, symmetrical, trachea midline and thyroid not enlarged, symmetric, no tenderness/mass/nodules ▪ Lungs: clear to auscultation bilaterally ▪ Chest Wall: No TTP ▪ Heart: regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop ▪ Abdomen: obese, non-tender; bowel sounds normal; no masses, no organomegaly ▪ Extremities: extremities normal, atraumatic, no cyanosis, +2 BLE nonpitting( pt states chronic) ▪ Neurologic: Mental status: Alert, oriented, thought content appropriate
HbA1c 5.4%
▪ CXR: No acute pulmonary process ▪ CTA Chest: No acute process, coronary calcifications
▪ Repeat troponins: 2.140, 4.520 ng/ml ▪ Patient treated medically for NSTEMI ▪ LHC done next day showed multivessel disease:
– 1. LVEF 70-75% no RWMA
vessel lesion: There is an 80% stenosis.
▪ Two days later patient underwent CABG (LIMA to LAD, SVG to PDA, ramus marginalis and posterior lateral branch of circumflex)
▪ Extubated same day, began having pleuritic chest pain the next day ▪ PE unremarkable, troponins down trending
▪ Unusual localized pericarditis ▪ LIMA to LAD occlusion ▪ Spasm
▪ No acute intervention was done as patient’s symptoms and EKG were not concerning enough that aggressive measures needed to be taken, and patient showed resolution in symptoms and EKG changes quickly ▪ Patient was discharged to cardiac rehab a few days later with following EKG
▪ Pericarditis is the most common cause of chest pain following and acute MI ▪ Typically occurs 1-2 months post cardiac injury (i.e. MI or CABG), referred to as Drexler Syndrome ▪ Hypothesized to be an autoimmune response ▪ Localized irritation of pericardium can produce focal ST-segment elevations and can be misdiagnosed as an acute STEMI ▪ No set criteria to diagnose
– Diffuse PR segment depressions with PR segment elevation in aVR
▪ Pericardial effusions may be seen in 85% of patient following CABG, friction rub much less common with an incidence of 13%
– Can be confused with mediastinal rub (surgical emphysema) frequently seen after cardiac surgery
▪ Recent office visit to cardiologist, no recurrence in symptoms and doing well
▪ UpToDate, Post-Cardiac Injury Syndromes ▪ Journal Article, The postcardiac injury syndrome: case report and review of the literature (2006) ▪ Journal Article, Post-cardiac injury syndromes. An emerging cause of pericardial diseases (2013)
Davis S. Mann
○ Colonoscopy 03/2014: Proximal sigmoid stricture ○ Colonoscopy 06/2017: Pancolonic Diverticulosis, colon polyp, rectal anastomosis
○ Dysphagia since 2016 (s/p intubations) ○ GI Consulted ■ Barium Swallow Study ■ EGD
Impression: Smooth long segment moderate stricture of the mid and distal esophagus
ischemic all the way down the EGJ…”
removable, completely covered esophageal stent placement
○ VS: BP 140s/80s, HR 100s, SpO2 96% on RA, RR 20
There are low density lesions scattered in the cerebral hemisphere and right cerebellum consistent with lipomas
dysfunction
vs leptomeningeal spread, no acute ischemic injury
○ “The scattered, small, fat density parenchymal foci present on the CT head examination previously are no longer on the current study” ○ Mild Cerebral Edema
○ Glucose 151, Protein 1277, 85, MEP negative, Herpes Negative, Lyme Negative, VDRL negative ○ Cytology: No malignant Cells ○ Fat stain and Lipid panel: Unable to be performed ○ Antibiotics/Antiviral discontinued
○ TCD w/ Bubble study: Did not show right to left shunting ○ TTE: “ Doppler shows no evidence of shunt. There is no evidence of right to left shunting with injection of agitated saline contrast” ■ EF 54%, RWMA noted consistent with Takotsubo Cardiomyopathy
○ CFD and doppler positive. There is evidence of shunting with injection of agitated saline contrast
○ Patient with minimal improvement
○ Drugs ○ Rupture of benign tumors
Uptodate: truncal rigidity and back arching Thought to be secondary to enduring refractoriness in inhibitory pathways of the cerebellum, brainstem, and spinal cord
○ Benzodiazepines: Accentuate GABA 1 receptors ○ Physostigmine: restpore spinal inhibition by stimulating Renshaw cell inhibition ○ Baclofen: GABA B agonist properties ○ Hydrocortisone: Potentiate glycine actions
to high pressure gradient (Right-to-left shunt) in an otherwise structurally normal heart, and then shoot up to the brain, all while withstanding rapid redistribution to the tissues and on-going metabolism?
○ Accumulation on surfactant with microemulsions absorbed by capillaries