ANSWERS WILL BE POSTED TOMORROW 3/2/17 at 13:00 CET

A 45-year old lady complained of central chest pain and shortness of breath. This was made worse on inspiration or when lying flat and is relieved on leaning forward.

She was currently receiving treatment for tuberculosis in the hospital under strict infection control.

1. What is the most likely diagnosis ?

2. What would you be able to auscultate in this patient ?

3. What are other clinical signs that you would look out for ?

4. What are the primary investigations that you would order ?

5. Describe the obtained ECG result seen below.



Source: http://hqmeded-ecg.blogspot.com.mt/2011/10/st-elevation-saddleback-what-is.html

6. How would you manage this patient ?

7. What is the major complication that may arise in this patient ?

Source: https://primeinc.org/casestudies/physician/study/534/Chest_Pain_from_Pericarditis

ANSWERS

1. Acute Pericarditis (Tuberculous pericarditis)

2. A pericardial friction rub heard over the apex. Upon auscultation, an extra heart sound of to- and fro- character, typically with three components, ONE systolic and TWO diastolic.

3. Other Clinical Features

Pulsus paradoxus

An abnormally large drop in systolic blood pressure and pulse wave amplitude during inspiration. The drop is typically more than 10 mmHg.

An abnormally large drop in systolic blood pressure and pulse wave amplitude during inspiration. The drop is typically more than 10 mmHg. Beck’s Triad

Low Blood Pressure, Distant heart sounds, Raise Jugular Venous Pressure

4. Routine Blood Investigations

FBC, ESR, CRP, U&E

Renal Function Tests, Thyroid Function Tests

Cardiac Enzymes: Troponin (may be raised) and CK-MB

Viral Serology, Blood cultures and Autoantibodies

Fungal Precipitants

ECG

See question below.

Chest X-ray

Look for cardiomegaly that may indicate pericardial effusion.

Echocardiography

If suspected pericardial effusion

Souce: http://www.slideshare.net/pratapsagar/pericarditis-42894065

5. From the ECG, one can observe a saddleback type of ST elevation in leads V2 and V3, as well as, diffuse T-wave inversion.

6. Management

Analgesia e.g. ibuprofen PO with food

Treat the tuberculosis infection as appropriate

Consider colchicine before steroids/immunosuppressants if relapse or continuing symptoms occur. 15-40% do recur.

If pericardial effusion or tamponade becomes evident, consider pericardiocentesis.

7. Pericarditis can progress to pericardial effusion and eventually cardiac tamponade.