WBR0017

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Author Raviteja Reddy Guddeti MBBS, Aarti Narayan MBBS (Reviewed by Gonzalo Romero)
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Cardiovascular
Prompt A-65-year old male presents to the ER due to a crushing retrosternal chest pain, which started 20 minutes ago. Additionally, he has nausea and diaphoresis. Following 2 hours of ER arrival, percutaneous coronary intervention is performed; he recovers over the next 5 days. 6 weeks following discharge, he returns to the office due to a mild retrosternal chest pain, which is aggravated when lying flat, and relieved when sitting up. Concomitantly, he has a mild cough and runny nose consistent with a recent upper respiratory tract infection. Complete blood count is within normal limits. What is the most likely diagnosis?
Answer A Viral pericarditis
Answer A Explanation Viral pericarditis is commonly caused by different virus such as: Coxsackie B, Echovirus, HIV or Adenovirus. It typically presents as an acute pericarditis with unspecific symptoms

It is important to consider the timeline of the chest pain occurring after the MI, which is 6 weeks in this case. The history of this patient is consistent with Dressler's syndrome.

Answer B Tuberculous pericarditis
Answer B Explanation [[AnswerBExp::Tuberculous pericarditis usually presents with night sweats, weight loss and fever. Pericardial fluid with an interferon-γ level greater than 50 pg/mL is highly specific for tuberculous pericarditis. There is nothing else in the patient history to suggest a past medical history of tuberculosis.]]
Answer C Post-cardiac injury pericarditis
Answer C Explanation Post-cardiac injury pericarditis, also known as post-myocardial infarction pericarditis has similar clinical presentation, but it occurs 2-4 days following an MI. The pathophysiology is thought to be of autoimmune origin due to a reaction to the myocardial neo-antigens.
Answer D Dressler’s syndrome
Answer D Explanation [[AnswerDExp::This patient is returning to the office due to Dressler syndrome, which is a post myocardial infarction syndrome. It is a form of pericarditis that occurs in the setting of injury to the heart (myocardial infarction). Typically, it occurs 2 to 10 weeks following a myocardial infarction.]]
Answer E Aortic dissection
Answer E Explanation [[AnswerEExp::The history of MI suggests that myocardial infarction is the inciting factor for the pericarditis.]]
Right Answer D
Explanation [[Explanation::This patient is returning to the office due to Dressler syndrome, which is a post myocardial infarction syndrome. It is a form of fibrinous pericarditis that occurs in the setting of injury to the heart (myocardial infarction). Typically, it occurs 2 to 10 weeks following a myocardial infarction. It is usually treated with aspirin.
  • Acute pericarditis presents between 6 weeks to 6 months of the disease onset. Acute pericarditis is more common than chronic pericarditis, and often occurs as a complication of viral infections, immunologic conditions, or as a result of a heart attack (myocardial infarction).
  • Subacute pericarditis presents within 6 weeks to 6 months of the disease onset
  • Chronic pericarditis manifests after 6 months of the disease onset. Chronic pericarditis is less common. It may manifest as scarring of the pericardium, which is a condition known as constrictive pericarditis.
Typical PresentationDiagnostic Tests
PericarditisPain aggravated supine and inspiration, alleviated when sitting, friction rubEKG with diffuse ST elevation and PR depressions followed by T-wave inversions
CostochondritisLocalized chest tenderness to palpation, localizedPhysical examination
Aortic dissectionAcute onset, tearing pain radiated to the back, asymmetric pulses and BP between upper extremities, chronic hypertensionCXR with mediastinal widening, chest CT angiogram, MRI or TEE
Pulmonary embolusSudden onset dyspnea, tachycardia and tachypneaSpiral CT, V/Q scan
PneumothoraxPleuritic pain, shortness of breath, deviated trachea, traumaCXR
PneumoniaProductive cough, hemoptysis, feverCXR
GERDAcidic taste, chronic cough, hoarsenssResponse to PPIs and antiacids
PUDBurning pain, change with eatingUpper endoscopy

Educational Objective: #Dressler syndrome is a form of pericarditis that presents 2 to 10 weeks following a myocardial infarction.

  1. The symptoms of pericarditis include: retrosternal chest pain aggravated when lying down and alleviated by sitting up. The EKG may show diffuse ST segment elevations and PR interval depression.

Remember the causes of pericarditis using this mnemonic CARDIAC RIND, which stands for:

  • Collagen vascular disease
  • Aortic dissection
  • Radiation
  • Drugs
  • Infections
  • Acute renal failure
  • Cardiac (MI)
  • Rheumatic fever
  • Injury
  • Neoplasms
  • Dressler's syndrome

References: Master the Boards for Step 2 CK, 2013 edition, page 54
Read more here: http://www.ncbi.nlm.nih.gov/pubmed/20194155]]

Approved Yes
Keyword MI, Pericarditis, Chest pain, Dressler syndrome
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