Case of chest pain

All photos (including ECG)  were taken by using Olympus E510 dSLR camera hand held with IS on and 50mm f/2.0 macro lens without flash.

disclaimer: this is only to demonstrate use of cameras in a clinical environment - use of clinical content at your own risk.


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Given the ECG, you go and see the patient and ask further about the pain and he volunteers that it is worse when he breathes and worse on lying down, now highly suggestive that your interpretation of the ECG is confirmed. A cardiorespiratory examination reveals no gross abnormality, in particular, no pericardial rubs and no evidence of cardiac tamponade or murmurs. But you notice a rash on his shin which on questioning he says is probably a spider bite as it developed yesterday and it is quite painful although no spider was seen. On further questioning he reveals that he actually had become unwell the day before the lesion on his shin developed and he felt like he had a flu-like illness and saw his LMO who started him on antibiotics. He has not been febrile and is at present constitutionally quite well apart from the chest pain and sore shin.

What are the differentials for this lesion:

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Well, it's possible it could have been a spider bite, although looks a bit atypical and given the absence of confluent erythema or fever, cellulitis is also not likely.

He has no clinical DVT or risk factors for DVT and he is not diabetic.

Any other ideas?

Well, although it is not truly nodular, it is only 24hrs old and I suspect it may well be erythema nodosum - if so, what other questions would you ask and what investigations would you do?

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If it is erythema nodosum, then it is likely that the erythema nodosum and the pericarditis are secondary to an underlying precipitant such as a viral infection (eg. Coxsackie, enterovirus) or other condition known to be a cause of EN.

He has no PH of inflammatory bowel disease or other problem of note.

On questioning, his father had actually developed a cardiomyopathy of an "infective" nature - could this be relevant?

An AP CXR was done as per routine for chest pain - what would you be specifically looking for here? Are there any features here that may help?

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Not sure of the relevance of his father's condition - but it may well be that it's not just a coincidence, but perhaps a genetic predisposition to a similar condition.

One condition that could cause both EN and pericarditis is sarcoidosis.

What are the CXR findings in sarcoidosis and what other investigations would you consider for this man?

How should he be managed?

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Disposition and management:

Given the acute nature of his illness, he was admitted for monitoring, primarily to ensure his pericarditis did not progress to myocarditis, pericardial effusions, or acute pericardial bleed and daily ECGs and a semi-urgent (within days) echocardiogram. 

In the interim, bloods were sent for CK, troponin (for myocarditis), ESR, serology for Coxsackie, ACE for sarcoidosis, and he was started on NSAIDs for symptomatic relief. 


Follow up & outcome:

Blood results from that evening showed CK 190 (normal 30-200) and troponin I 5.52 (normal <0.1), WCC 9.0, ESR 37.

Repeat bloods at 5am overnight showed CK 429 & troponin I 19.38, CRP 51.

The high troponin made the cardiology team anxious and he was transferred for immediate angiography which not surprisingly was normal and a diagnosis of pericarditis was re-confirmed.

For the photographers, here is a 100% crop of the ECG without any post-processing other than compression for web:

not bad for hand-held in ambient office lighting - just shows how good the Olympus E510 with ZD 50mm f/2.0 macro combination is!

All photos (including ECG)  were taken by Dr G.Ayton using Olympus E510 dSLR camera hand held with IS on and 50mm f/2.0 macro lens without flash.

Copyright G Ayton 2007