Myopericarditis in an emergency department patient presenting with chest pain and ECG changes: a case report.

Abstract

Background: Myopericarditis is uncommon but important to consider in patients presenting with chest pain. It most commonly is caused by a viral infection. Myopericarditis involves both myocardial injury and pericardial sac inflammation, thus may benefit from close monitoring and expedited treatment. It can present like pericarditis with chest pain, cold-type symptoms, diffuse ST elevations and PR depressions on electrocardiogram (ECG), and pericardial effusion on ultrasound. Risk stratification depends on case severity. More severe cases of myopericarditis can demonstrate elevated troponins and myocardial involvement, including potential left ventricular dysfunction.

Case presentation: We describe an 81-year-old male patient with three days of pleuritic chest pain, dyspnea on exertion, and upper respiratory infection symptoms. He was evaluated by cardiology due to diffuse ST elevations on his ECG but did not have reciprocal changes, making acute coronary syndrome (ACS) less likely. His workup showed elevated inflammatory markers and elevated high-sensitivity troponin levels, indicating myocardial injury and distinguishing his diagnosis from pericarditis. His respiratory viral panel was negative. Bedside ultrasound showed a small pericardial effusion and moderately reduced ejection fraction (EF 40%). He was initiated on treatment for myopericarditis with colchicine and high-dose ASA (650 mg three times daily) for 3-4 weeks, with significant symptom improvement within 1-2 days.

Conclusions: Emergency physicians should initiate early treatment for myopericarditis to reduce inflammation for improved patient outcomes while still considering ACS in all patients presenting with chest pain. Point-of-care ultrasound can identify a pericardial effusion or acute heart failure to guide management. Patients with myocardial involvement can develop permanent heart damage but can exhibit excellent recovery with appropriate treatment, which includes nonsteroidal anti-inflammatories, colchicine, and high-dose ASA.