Aligned with the American Board of Pediatrics format. Authored & peer-reviewed by fellowship-trained clinicians.
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A previously healthy 15-year-old boy is admitted to the general pediatric floor for evaluation of chest pain. His pain began the evening prior to admission. He describes it as sharp and reports he was unable to sleep well due to worsening when he lay supine. He also explains that leaning forward seems to relieve his discomfort. On examination, his vital signs include RR 24/min, HR 124 bpm, and BP 125/87 mm Hg. He is afebrile and not hypoxic on room air. He appears uncomfortable but is not in respiratory distress. On palpation of his chest, no tenderness is elicited. On auscultation, breath sounds are clear and equal bilaterally, and the heart rhythm is regular with a normal S1 and S2. There is no S3. When the patient leans forward, a friction rub is heard at the left upper sternal border. An ECG shows diffuse ST segment elevations. Which of the following is the most appropriate initial treatment?
Pericarditis, the inflammation of the pericardium, is a common cardiac cause of acute chest pain in the pediatric population. The majority of cases are idiopathic, but a viral history is often elicited. A virus may either cause direct pericardial infection or a reactive inflammation of the pericardium. Less commonly, pericarditis may be bacterial, autoimmune, or malignant in etiology. The typical pain of pericarditis is midsternal and may radiate to the left shoulder. It is also frequently positional: worse when lying supine and improved when leaning forward. Patients may also report worsening with deep inspiration or associated abdominal pain. Examination findings include tachypnea, tachycardia, and a pericardial friction rub. In cases with a large pericardial effusion and evolution toward cardiac tamponade, pulsus paradoxus may also be noted. Initial evaluation should include an electrocardiogram, which typically shows diffuse ST segment elevations in leads I, II, III, and V1–V6 and may also reveal PR segment depressions. An echocardiogram should also be obtained to evaluate for any associated pericardial effusion but should not delay the clinical diagnosis and management of suspected cardiac tamponade. In the absence of a pericardial effusion, a chest X-ray will usually be normal. Laboratory studies are typically nonspecific and may reveal elevated inflammatory markers, elevated troponin I levels, or positive viral titers. The mainstay of therapy is oral NSAIDs, particularly ibuprofen or naproxen, which should be scheduled and administered until the inflammatory markers have normalized and symptoms have resolved. Gastrointestinal prophylaxis with a proton pump inhibitor is indicated for the prolonged NSAID course.
There is evidence the addition of colchicine (A) to a pericarditis treatment regimen may decrease the risk of recurrence of pericarditis, but it is not the first-line treatment of acute pericarditis in adolescents. Nitroglycerin (C) may be used in the management of other sources of acute chest pain, including myocardial infarction, but is not indicated for acute pericarditis. Prednisone (D) and other systemic corticosteroids, while potent in their anti-inflammatory effect, may increase the risk of recurrence of pericarditis and is not first-line therapy, though they may be considered for patients in whom NSAIDs are contraindicated.
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Q: Which viruses are most commonly associated with pericarditis?Reveal Answer
A: Adenovirus and coxsackievirus.
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