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Number 10-24: Acute Idiopathic Pericarditis
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Number 10-24: Acute Idiopathic Pericarditis

Authors:  Bratis K (1), Mavrogeni S (2), Potsios D (1), Mitropoulou E (1), Mpoutos G (1), Mantzouratos D (1)
Institution:  (1) Cardiology Department, Patision General Hospital, Athens, Greece & (2) A' Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece

Case: A 58-year old man, free from any previous medical history, presented to the emergency department with retrosternal oppressive chest pain, varying with inspiration and posture, of rapid installation and evolution after prolonged direct exposure to cold airflow from an air-conditioner.
The ECG on admission showed a PR segment depression associated to anterior and inferior concave ST segment elevation, (Fig. 1).



Figure 1 


Despite an initial normal clinical examination and a modest inflammatory profile as the only laboratory finding, the hypothesis of acute pericarditis arose. Echocardiography was strictly normal (Figure 2 - apical four-chamber end-diastolic view; Figure 3 - parasternal long-axis view).



 Figures 2 & 3 [right click mouse to enlarge]


A CT scan (Fig. 4) was urgently performed - pending the availability of CMR imaging - which depicted a thickening of the pericardium, without pericardial effusion but with mild bilateral pleural effusion.



Figure 4 [right click mouse to enlarge]


CMR was then performed. LV end-diastolic volume (164mL) and ejection fraction (64%) were normal, as assessed by cine balanced SSFP imaging (Movie 1, four-chambers view).




Movie 1


Short -inversion recovery T2-weighted imaging with fat suppression demonstrated hyperintense signal from the pericardium (arrowed in Fig. 5), particularly sensitive for tissue oedema, a substantial feature of an acute inflammation reaction. There was neither myocardial oedema, nor pericardial effusion.


Figure 5


Contrast-enhancement inversion recovery imaging before contrast administration (Fig. 6), and in the late phase after gadolinium injection (Fig. 7), showed a significant circumferential homogenous thickening of both visceral and parietal pericardium, measuring approximately 7mm, with significant contrast enhancement, which may be due to severe oedema and/or cellular necrosis. There was no evidence of late contrast myocardial enhancement, permitting thus to exclude any associated myocardial fibrosis or acute myocarditis.



 Figures 6 & 7


A symptomatic treatment with non steroid anti inflammatory drugs (ibuprofen 800 mg per os three times daily) was initiated with a gratifying response and complete relief of the symptoms from the second dose of NSAID.
An ultimate etiological control was negative.

Discussion/ Perspective: Acute pericarditis, defined as symptoms and/or signs resulting from pericardial inflammation of no more than 1 to 2 weeks' duration, may occur in a wide variety of diseases, but the majority of cases are idiopathic, with no specific etiology found with routine diagnostic testing. (1) The incidence of acute pericarditis is difficult to quantify because there are undoubtedly many undiagnosed cases. (2)

We describe a case of acute idiopathic pericarditis, in which diagnosis was based mainly on the clinical findings, and confirmed by advanced imaging techniques. Beside the rarity of similar images in the literature (3, 4) we find quite intriguing the fact that in an era of intense debate on the competitive role of the various cardiac imaging exams, this case delinates a condition in which conventional techniques, like echocardiography, fail to contribute to the diagnosis. Cardiac CT and CMR with the use of tissue characterisation techniques, permit the acquisition of high quality images depicting inflammation, leading  to the confirmation of a diagnosis known till now to derive on exclusion.  

1. Lange RA, Hillis LD.   Acute pericarditis.  N Engl J Med  2004; 351:2195-202.

2. Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmüller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH. Guidelines on the diagnosis and management of pericardial diseases executive summary; the Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology.  Eur Heart J  2004; 25:587.

3. Koos R, Schröder J, Kühl HP. Acute viral pericarditis without typical electrocardiographic changes assessed by cardiac magnetic resonance imaging. Eur Heart J. 2009 Dec;30(23):2844.

4. Sa MI, Kiesewetter CH, Jagathesan R, Prasad SK. Images in Cardiovascular Medicine. Acute pericarditis assessed with magnetic resonance imaging: a new approach. Circulation. 2009 Feb 3;119. 

COTW Handling Editor:  Monica Deac


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