Chest Pain - Cross Country

Abstract

HISTORY: A 21-year-old female college cross country runner presented with chest pain, upper abdominal pain, and thoracic back pain for the last week. She was seen 5 days previously for fever/chills, muscle aches, and pleuritic chest pain. She was diagnosed with influenza, took Oseltamivir, and her symptoms resolved except for chest and upper abdominal pain with fatigue. Chest pain is mid- to slightly left-sided. She complains of fatigue with any exertion. She has been taking a large amount of Ibuprofen. PHYSICAL EXAMINATION: Examination revealed regular heart rate and rhythm without friction rub while sitting or in hip forward flexion. Normal lung auscultation. Nasal exam showed boggy, erythematous, and edematous turbinates with rhinorrhea bilaterally. There was mild oropharynx erythema with normal tonsils. Abdominal exam showed mild epigastric tenderness. Kernig and Brudzinski tests were negative. DIFFERENTIAL DIAGNOSIS: 1. Acute Gastritis 2. Acute Pericarditis or Myocarditis 3. Community-Acquired Pneumonia TEST AND RESULTS: Chest radiographs: — mildly enlarged cardiac silhouette, blunting of the costophrenic angles bilaterally 12-lead Electrocardiogram: — Diffuse ST elevation sparing AVR, V1 and lead 3; reciprocal changes in AVR; periodic PR depression Echocardiogram: — normal left ventricle size, motion, and function with an ejection fraction of 60%. — small, generalized pericardial effusion. — no evidence of cardiac tamponade FINAL/WORKING DIAGNOSIS: Acute Pericarditis TREATMENT AND OUTCOMES: 1. Referred to Cardiology. Placed on scheduled Ibuprofen. Cardiology returned her to activity 2 weeks after symptoms stopped. 2. Hospitalized for chest pain flare after return to activity. Repeat echocardiogram showed moderate pleural effusion. Started on Prednisone and told to rest for 3 months. 3. Referred to Rheumatology who felt this was likely viral but placed her on Hydroxychloroquine in addition to Prednisone. 4. Now tapering Hydroxychloroquine and Prednisone per Rheumatology. 5. Undergoing a gradual return-to-run progression over a 2-3 month time period with frequent monitoring. Started progression when she had normal inflammatory markers and no effusion on echocardiogram 9 months after symptoms began.