A 46-year-old male was admitted to hospital for treatment of recurrent pericarditis. The patient was hospitalized for treatment of acute pericarditis in 2006 complaining of chest and right shoulder pain. Other complaints at that time included a mild cold and fever lasting for several days prior to admission. The blood test showed leukocytosis - WBC 11.08 x 109/l (with a shift to the left) and elevated CRP 86.5 mg/l. The electrocardiogram (ECG) showed a sinus rhythm, ST segment elevation in leads I, II, III, and aVF. ECG findings remained without any changes during the hospitalization period. Mild left ventricular hypertrophy and impaired left ventricular diastolic function were seen on the transthoracic echocardiogram (TTE). The patient's condition improved with the administration of non-steroidal anti-inflammatory drugs (NSAIDs) and he was discharged after a nine-day stay in hospital with complete resolution of symptoms.
Three months after discharge, the patient was brought to the emergency department complaining of chest pain and shortness of breath present at limited physical activity and at rest. Other complaints included palpitations and fever as high as 38.5 C. The ECG showed sinus tachycardia with inverted T-wave in all ECG leads. The TTE showed pericardial effusion distributed around the heart (0.8-1 cm). Leukocytosis with a shift to the left and elevated CRP were present (WBC 12.8 x 109/l, CRP - 203 mg/l). Based on this clinical picture, recurrent pericarditis was diagnosed and the patient was hospitalized. The patient developed renal insufficiency during the period of admission (serum creatinine was 168 micromol/L). The renal function recovered after stimulating diuresis. The patient received treatment with NSAIDs (diclofenac) and 6 million units of penicillin per day intravenously. The chest computed tomography (CT) scan performed before discharge from hospital revealed a thickened pericardium of 4 mm and fibrotic changes is both lungs. A conclusion that a disease relapse occurred, most likely, due to patient terminated treatment of acute pericarditis earlier against medical recommendation was made. Because of a slow onset, prolonged disease course, fibrotic heart and lung changes on the CT, tuberculous pericarditis was suspected but as tuberculosis was not confirmed, this diagnosis was ruled out. Seven days from admission to the hospital the patient's condition improved and he was discharged. Patient had no complaints after hospitalization.
In 2016, ten years after the treatment of recurrent pericarditis, the patient was brought by ambulance to Vilnius University Hospital Santaros klinikos with chest discomfort relieved with nitroglycerin. Other relative symptoms included shortness of breath, weakness, and fever as high as 38 C with chills. The patient had a history of smoking and was suffering from hypertension. On admission, the patient had fever of 38.1 C, blood pressure was 130/80 mmHg, pulse - 100 beats per minute, no murmur was noted on examination, and no oedema of the limbs was present. The blood test showed leukocytosis with a shift to the left (WBC 13.66 x 109/l), elevated CRP - 42.4 mg/L, and D-dimer - 800 mkg/L levels. In the emergency department, cardiac-enzyme levels were found to be normal. Based on laboratory findings, the patient's medical history, and the data of previous hospital admissions, recurrent pericarditis was suspected and the patient was hospitalized for further treatment and clinical investigation. The patient's high fever persisted, so blood and urine culture tests were done but both were negative for bacteria. The ECG showed sinus tachycardia and an inverted T wave in leads V1-V6 (Figure).
A moderate-sized pericardial effusion (1.7 cm) was seen on the TTE. The patient received Sol. Amoxiclavi 1.2 g twice daily, NSAIDs (prolonged-release diclofenac tablets 75 mg per day), oral perindopril, beta-blockers, and Aspirin. The patient's condition improved with the prescribed treatment, and the fever and inflammation markers started decreasing: leukocytosis 13.66   13   10.45 x 109/l, CRP 42.4   33.5   9.8 mg/L. A repeat TTE showed moderate-sized and hemodynamically insignificant pericardial effusion (less than 1 cm echo-free space apically and around the left atrium). ECG showed a sinus rhythm without other significant changes. The patient was discharged six days from admission to hospital with complete resolution of the symptoms. He was recommended to continue taking aspirin and beta-blockers, and to continue the treatment of hypertension. The patient was also urged to give up smoking and to control his body weight, and benefits of regular physical activity were also emphasized. The patient had no complaints of chest pain since the latest hospital admission; hypertension was controlled adequately.