Authors
Alexa R. Gale, MD
House Staff
Department of Emergency Medicine
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, New Jersey
Disclosure: Alexa R. Gale, MD, has disclosed no relevant financial relationships.
Raffi Kapitanyan, MD
Assistant Professor
Department of Emergency Medicine
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, New Jersey
Disclosure: Raffi Kapitanyan, MD, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Diagnostic Radiology
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Eric Yang, MD
Associate Professor of Medicine, Director of Interventional Cardiology Fellowship Program
Henry Ford Hospital
Detroit, Michigan
Disclosure: Eric Yang, MD, has disclosed no relevant financial relationships.
Infectious and inflammatory conditions of the pericardium and myocardium may present with occult symptoms or rapid cardiovascular collapse. The large overlap in presentation of pathologic processes makes it difficult to readily distinguish among different root etiologies. A series of clinical cases will hone your diagnostic acumen and ensure you can readily identify, triage, and treat diseases of the pericardium and myocardium. The ultrasound image shown demonstrates a pericardial effusion.
A 36-year-old woman presents with palpitations and chest pain that radiates to her back and left arm for several days. It is worse with inspiration or lying flat and alleviated by leaning forward. She has felt subjectively hot and has a nonproductive cough with shortness of breath. Her vital signs show a temperature of 100.9°F, heart rate of 100 bpm, blood pressure of 132/86 mm Hg, respiratory rate of 22 breaths/min, and oxygen saturation of 97%. A friction rub is heard over the left lower sternal edge during end expiration while the patient is sitting up and leaning forward. The ECG is shown courtesy of Wikimedia Commons.
What is the most likely diagnosis?
A. Acute myocardial infarction (MI)
B. Acute pericarditis
C. Pneumothorax
D. Pulmonary embolism
Answer: B. Acute pericarditis
There are several types of acute pericarditis. Serous pericarditis usually has a noninfectious cause, such as rheumatoid arthritis. Fibrous and serofibrinous pericarditis are often seen after infarction, such as Dressler syndrome (seen 2 weeks after MI), and trauma. In purulent or suppurative pericarditis, organisms spread via the blood, the lymphatic system, or direct extension. Hemorrhagic pericarditis is usually seen in patients with tuberculosis or is caused by direct neoplastic invasion. Image courtesy of Wikimedia Commons.
ECG changes are as follows:
Stage 1: ST-segment elevations throughout (arrows), except in AVR and V1
Stage 2: Days later, normal ST segments and flat T waves
Stage 3: T-wave inversion
Stage 4: Months later, persistent T-wave inversion from chronic inflammation
Viral myocarditis is a form of dilated cardiomyopathy that presents with fever, rigor, myalgia, and headache. Patients may have angina with pericardial friction rub. ECG changes are usually nonspecific, with ST-segment elevation from concomitant pericarditis, AV block, and QRS prolongation. Cardiac enzymes may be elevated. Viral myocarditis is due to myocardial inflammatory changes and infiltration with inflammatory mediators, such as lymphocytes and plasma cells. Common viruses include enteroviruses (eg, coxsackievirus and echovirus) and adenoviruses. Treatment is supportive, but antibiotics can be used if the disease course is complicated by rheumatic fever or meningococcemia.
A 32-year-old man who is a known intravenous drug user presents with a temperature greater than 100.4°F, cough, chest pain, and malaise. He is worried because painful nodules have appeared on his palms and fingers, (shown). Image courtesy of Wikimedia Commons.
What does this image show?
A. Splinter hemorrhages
B. Janeway lesions
C. Roth spots
D. Osler nodes
Answer: D. Osler nodes
Osler nodes are painful deposits associated with immune complexes (arrows). They are seen in infective endocarditis, systemic lupus erythematosus (SLE), and disseminated gonococcal infections. Splinter hemorrhages are linear lesions in nail beds; they can also be seen in trauma, scleroderma, SLE, and rheumatoid arthritis. Janeway lesions are nontender macules on the palms or soles resulting from microabscesses due to septic emboli. They are pathognomonic for infective endocarditis. Roth spots are seen on fundoscopic examination as retinal hemorrhages with clear centers. Image courtesy of Wikimedia Commons.
A 45-year-old patient with infective endocarditis suddenly deteriorates with worsening congestive heart failure, new-onset murmurs, and regurgitation. Unfortunately, the patient does not survive the cardiovascular insult. Findings from a postmortem examination are shown.
What condition did the patient have?
A. Myocardial abscess
B. Myocardial infarction
C. Myocardial fibrosis
D. Myocardial hypertrophy
Answer: A. Myocardial abscess
This patient had a myocardial abscess, which is a suppurative infection of the myocardium. The collections can also be seen on valves and or adjacent structures. This is a serious complication of infective endocarditis and is a medical emergency requiring early intervention for patient survival. Because most patients have underlying endocarditis, they present with symptoms signaling worsening of their illness (eg, fever and chest pain), congestive heart failure, and development of cardiac conduction abnormalities. Immediate management should include hemodynamic stabilization, antibiotics, and surgical consultation for evacuation of abscess.
Not all cases of endocarditis are infectious in origin. This echocardiogram shows mitral valve masses similar to those seen in Libman-Sacks endocarditis. These vegetations are sterile and have been described as mulberry-like in postmortem examinations. This type of endocarditis is associated with SLE, an autoimmune disease that produces immune complexes with the ability to stick to cardiac valves, causing regurgitation and in some cases stenosis. Although these vegetations often involve left-sided heart valves, all valves can be involved. Most patients are asymptomatic, but some may present with symptoms of cardiac failure late in the course of the disease.
A 13-year-old girl presents with chest pain, ascites, dyspnea, and easy fatigability on exertion. The patient has a history of multiple cardiac surgeries to correct a congenital heart defect. On physical examination, you note an increase in jugular venous pressure on inhalation and a distinct knock on auscultation of the left sternal border. Image courtesy of Tal Geva, MD.
What is the patient's diagnosis?
A. Constrictive pericarditis
B. Congestive heart failure
C. Infective endocarditis
D. Myocarditis
Answer: A. Constrictive pericarditis
This patient has constrictive pericarditis. The 2 physical signs were the Kussmaul sign (in which the jugular venous pressure increases on inhalation) and a pericardial knock (in which ventricular filling is inhibited by the thickened pericardium). Patients may also present with ascites, edema, and hepatosplenomegaly. A calcified pericardium can sometimes be visualized on chest radiography. This image is an MRI scan that shows a thickened and calcified pericardium (arrow). ECG changes are nonspecific S-T changes and low voltage QRS complexes. Management is mainly surgical, and most patients require pericardectomy. Image courtesy of Tal Geva, MD.
A 36-year-old man with known HIV infection presents with 4 days of chest pain and dyspnea. He says his HIV medications "are too hard to take." On examination, you hear muffled heart sounds and see jugular venous distention with hypotension. There is dullness to percussion below the angle of the left scapula. The systolic pressure decreases by 12 mm Hg with each inspiration. His chest radiograph is shown.
What is the diagnosis, and what are the 3 key physical examination signs?
A. Pleural effusion: decreased breath sounds, tactile fremitus, and egophony
B. Ascites: Jaundice, palmar erythema, and spider angiomas
C. Pericardial effusion: Beck triad, Ewart sign, and pulsus paradoxus
D. Infective endocarditis: Janeway lesions, Roth spots, and Osler nodes
Answer: C. Pericardial effusion: Beck triad, Ewart sign, and pulsus paradoxus
This patient has a pericardial effusion. The Beck triad of cardiac tamponade is present when there are muffled heart sounds due to excessive fluid and decreased contractility of the heart, jugular venous distention (a sign of right-sided heart failure), and hypotension. The second finding is the Ewart sign, in which fluid accumulation around the heart causes dullness to percussion at the base of the left scapula. The third finding is pulsus paradoxus, which is an increase in the systolic blood pressure with inspiration due to right-sided heart failure.
Pericardial effusions are an abnormal accumulation of fluid in the pericardial space. There is normally 15-50 mL of fluid present for lubrication between the visceral and parietal pericardium. An acute accumulation of 80 mL of fluid can increase pressures and cause symptoms. A chronic accumulation can amass as much as 2 L of fluid before any significant clinical findings occur. Patients with pericardial effusions may present with chest pain that is alleviated by sitting forward. Other symptoms include palpitations, cough, and dyspnea. This subcostal ultrasound image shows a large pericardial effusion (arrows) impeding outflow. Surgical consultation should be requested to perform a pericardial window with pericardiostomy.
The same 36-year-old patient with HIV presents again after leaving the emergency department without being seen. He states, "I just can't breathe, and my heart is racing." You immediately notice that his extremities are cold and clammy. You rush-perform a bedside ultrasound and see this image.
What is the patient's diagnosis?
A. Pleural effusion
B. Acute MI
C. Pericardial effusion
D. Cardiac tamponade
Answer: D. Cardiac tamponade
This subcostal view shows cardiac tamponade with early collapse of the right ventricle, which is a cardiac emergency. This patient's workup should include a complete blood count and comprehensive metabolic panel to look for infectious causes and a renal profile. Cardiac enzyme and troponin levels are elevated in cardiac trauma and MI. In addition, a coagulation panel should be ordered to determine the risk of bleeding during surgical intervention, such as pericardiocentesis or pericardial window. Blood type and cross-type should be determined in case the patient needs a transfusion after the procedure.
In cardiac tamponade, the pericardial fluid under pressure compresses the heart, leading to an equalization of the diastolic pressure within each heart chamber. This restricts the diastolic filling of the ventricles, producing clinical signs of right heart failure and pulmonary venous congestion. This blunts the systolic descent (y descent) from a right atrial pressure tracing. Image courtesy of Wikimedia Commons.
An ECG from a patient with cardiac tamponade reveals which classic finding?
A. Electrical alternans
B. Flattened P waves
C. ST-segment elevations
D. Low voltage signals
Answer: A. Electrical alternans
Electrical alternans is an alteration in the height of the QRS complexes, often seen in cardiac tamponade (shown). In this medical emergency, excessive fluid in the pericardial sac impedes ventricular filling, causing hemodynamic compromise. Classic physical findings are the Beck triad; pulsus paradoxus; and the Kussmaul sign, which is an increase in venous distention and pressure during inhalation. Image courtesy of Wikimedia Commons.
Pericardiocentesis is a procedure to remove pericardial fluid in cardiac tamponade to improve hemodynamic status. Ideally, this procedure is performed with ultrasound guidance. Patients should be positioned in either the supine position or at a 45-degree angle. The most common pericardiocentesis sites are the left sternal margin and subxiphoid (black dots). When performing pericardiocentesis, prepare the area in an aseptic technique and incise the skin with a scalpel. Connect a spinal needle to a 60-mL syringe with 5 mL of normal saline. The needle should be inserted at a 45-degree angle off the midline, directing it toward the patient's left shoulder.
While inserting the needle, simultaneously inject saline to ensure patency of the needle lumen. If any ST-segment changes occur on the cardiac monitor, withdraw the needle until the pattern returns to normal. Advance the needle to a depth of 5 cm with negative pressure held on the syringe. Direct visualization of the needle tip can be performed via ultrasound (shown). Withdraw as much fluid as possible, ensuring that there are no changes on the cardiac monitor.
Authors
Alexa R. Gale, MD
House Staff
Department of Emergency Medicine
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, New Jersey
Disclosure: Alexa R. Gale, MD, has disclosed no relevant financial relationships.
Raffi Kapitanyan, MD
Assistant Professor
Department of Emergency Medicine
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, New Jersey
Disclosure: Raffi Kapitanyan, MD, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Diagnostic Radiology
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Eric Yang, MD
Associate Professor of Medicine, Director of Interventional Cardiology Fellowship Program
Henry Ford Hospital
Detroit, Michigan
Disclosure: Eric Yang, MD, has disclosed no relevant financial relationships.
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