ILLUSTRATIVE CASE
Chest Pain in Two Athletic Male Adolescents Mimicking Myocardial Infarction Sachin K. Gupta, MD* and Zahra Naheed, MDÞ
Abstract: Acute chest pain with elevated troponin and CK-MB levels and focal ST elevation on electrocardiogram is considered to be myocardial infarction unless proven otherwise. The cardiac enzymes can be elevated in other etiologies of chest pain including myopericarditis, pulmonary embolism, acute rheumatic fever, and trauma. Therefore, patients presenting with chest pain and elevated cardiac enzymes should be carefully evaluated for other etiologies after ruling out acute coronary process. We report 2 male adolescents with myopericarditis who presented to the emergency department with chest pain and elevated cardiac enzymes. Key Words: electrocardiogram, shortness of breath, nonsteroidal anti-inflammatory drugs; magnetic resonance imaging; premature ventricular contractions (Pediatr Emer Care 2014;30: 493Y495)
drugs. The ECG on the second day of admission showed monomorphic, nonsustained ventricular tachycardia; however, all other ECGs done thereafter were normal. Follow-up echocardiograms revealed slightly decreased ejection fraction (40%Y50%) but no regional wall motion abnormalities. A cardiac magnetic resonance imaging (MRI) was performed and showed nonvascular subepicardial enhancement characteristically involving the lateral wall of the left ventricular mid and apical chamber together with pericardial enhancement most suggestive of myopericarditis. The follow-up laboratory tests, including throat and stool viral cultures and coxsackieviruses B1-B5 antibody titers remained negative. Patient was discharged with an event monitor and prescription for carvedilol and enalapril. He remained asymptomatic for 16 weeks, until the time of submission of this case report.
CASE 2 CASE 1 A 16-year-old athletic, African American boy presented to the pediatric emergency department (ED) with sudden onset of sharp retrosternal chest pain. The pain started after prolonged standing and was nonpleutritic and constant. He reported no radiation of pain or other associated symptoms such as shortness of breath, diaphoresis, nausea, or vomiting. He was given acetaminophen twice without improvement before arrival to the pediatric ED. He had no risk factors for coronary artery disease, and no significant medical history was reported except mild viral illness 10 days prior. On examination, he was in acute pain; temperature was 98-F; heart rate, 51 beats/min; respiratory rate, 18 breaths/min; oxygen saturation, 98% to 100% on room air; and blood pressure, 101/62 mm Hg. There was no murmur, rub, or gallop; no chest wall tenderness; normal jugular venous pressure, normal respiratory examination; and no hepatomegaly. The initial 12-lead electrocardiogram (ECG) (Fig. 1) showed sinus bradycardia, with occasional premature ventricular contractions (PVCs) and ST elevations in leads II, III, and aVF. Troponin I and CK-MB were markedly elevated (troponin I 219 ng/mL at 8 hours; CK-MB 159 ng/mL at 24 hours). The toxicology screen was negative. A stat echocardiogram revealed normal left ventricular ejection fraction without regional wall motion abnormalities, normal origin of coronary arteries, and mild pericardial effusion. The working diagnosis of myopericarditis was established in view of young age and no other risk factors. Chest pain subsided 4 hours after admission after giving nonsteroidal anti-inflammatory drugs. CK-MB normalized over the next 4 days, but troponin I remained slightly elevated (0.422 ng/mL). The patient did have some episodes of chest pain after admission but subsided with nonsteroidal anti-inflammatory From the Departments of *Pediatrics and †Pediatric Cardiology, John H Stroger Jr, Cook County Hospital, Chicago, IL. Disclosure: The authors declare no conflict of interest. Reprints: Sachin K. Gupta, MD, John H Stroger Jr, Cook County Hospital, Pediatrics, 1901 W Harrison St, Chicago, IL 60612 (e
Chest Pain in Two Athletic Male Adolescents Mimicking Myocardial Infarction Sachin K. Gupta, MD* and Zahra Naheed, MDÞ
Abstract: Acute chest pain with elevated troponin and CK-MB levels and focal ST elevation on electrocardiogram is considered to be myocardial infarction unless proven otherwise. The cardiac enzymes can be elevated in other etiologies of chest pain including myopericarditis, pulmonary embolism, acute rheumatic fever, and trauma. Therefore, patients presenting with chest pain and elevated cardiac enzymes should be carefully evaluated for other etiologies after ruling out acute coronary process. We report 2 male adolescents with myopericarditis who presented to the emergency department with chest pain and elevated cardiac enzymes. Key Words: electrocardiogram, shortness of breath, nonsteroidal anti-inflammatory drugs; magnetic resonance imaging; premature ventricular contractions (Pediatr Emer Care 2014;30: 493Y495)
drugs. The ECG on the second day of admission showed monomorphic, nonsustained ventricular tachycardia; however, all other ECGs done thereafter were normal. Follow-up echocardiograms revealed slightly decreased ejection fraction (40%Y50%) but no regional wall motion abnormalities. A cardiac magnetic resonance imaging (MRI) was performed and showed nonvascular subepicardial enhancement characteristically involving the lateral wall of the left ventricular mid and apical chamber together with pericardial enhancement most suggestive of myopericarditis. The follow-up laboratory tests, including throat and stool viral cultures and coxsackieviruses B1-B5 antibody titers remained negative. Patient was discharged with an event monitor and prescription for carvedilol and enalapril. He remained asymptomatic for 16 weeks, until the time of submission of this case report.
CASE 2 CASE 1 A 16-year-old athletic, African American boy presented to the pediatric emergency department (ED) with sudden onset of sharp retrosternal chest pain. The pain started after prolonged standing and was nonpleutritic and constant. He reported no radiation of pain or other associated symptoms such as shortness of breath, diaphoresis, nausea, or vomiting. He was given acetaminophen twice without improvement before arrival to the pediatric ED. He had no risk factors for coronary artery disease, and no significant medical history was reported except mild viral illness 10 days prior. On examination, he was in acute pain; temperature was 98-F; heart rate, 51 beats/min; respiratory rate, 18 breaths/min; oxygen saturation, 98% to 100% on room air; and blood pressure, 101/62 mm Hg. There was no murmur, rub, or gallop; no chest wall tenderness; normal jugular venous pressure, normal respiratory examination; and no hepatomegaly. The initial 12-lead electrocardiogram (ECG) (Fig. 1) showed sinus bradycardia, with occasional premature ventricular contractions (PVCs) and ST elevations in leads II, III, and aVF. Troponin I and CK-MB were markedly elevated (troponin I 219 ng/mL at 8 hours; CK-MB 159 ng/mL at 24 hours). The toxicology screen was negative. A stat echocardiogram revealed normal left ventricular ejection fraction without regional wall motion abnormalities, normal origin of coronary arteries, and mild pericardial effusion. The working diagnosis of myopericarditis was established in view of young age and no other risk factors. Chest pain subsided 4 hours after admission after giving nonsteroidal anti-inflammatory drugs. CK-MB normalized over the next 4 days, but troponin I remained slightly elevated (0.422 ng/mL). The patient did have some episodes of chest pain after admission but subsided with nonsteroidal anti-inflammatory From the Departments of *Pediatrics and †Pediatric Cardiology, John H Stroger Jr, Cook County Hospital, Chicago, IL. Disclosure: The authors declare no conflict of interest. Reprints: Sachin K. Gupta, MD, John H Stroger Jr, Cook County Hospital, Pediatrics, 1901 W Harrison St, Chicago, IL 60612 (e
