WBR0017

Author	PageAuthor::Raviteja Reddy Guddeti MBBS, Aarti Narayan MBBS (Reviewed by Gonzalo Romero)
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A-65-year old male presents to the ER due to a crushing retrosternal chest pain, which started 20 minutes ago. Additionally, he has nausea and diaphoresis. Following 2 hours of ER arrival, percutaneous coronary intervention is performed; he recovers over the next 5 days. 6 weeks following discharge, he returns to the office due to a mild retrosternal chest pain, which is aggravated when lying flat, and relieved when sitting up. Concomitantly, he has a mild cough and runny nose consistent with a recent upper respiratory tract infection. Complete blood count is within normal limits. What is the most likely diagnosis?]]
Answer A	AnswerA::Viral pericarditis
Answer A Explanation	[[AnswerAExp::Viral pericarditis caused by different virus, commonly Coxsackie B virus, Echovirus, HIV or Adenovirus. It typically presents as an acute pericarditis. It is important to consider the timeline of the chest pain occurring after the MI, which is 6 weeks in this case. The history of this patient is consistent with Dressler's syndrome.]]
Answer B	AnswerB::Tuberculous pericarditis
Answer B Explanation	[[AnswerBExp::There is nothing else in the patient history to suggest a different form of pericarditis, and no past medical history of tuberculosis.]]
Answer C	AnswerC::Post-cardiac injury pericarditis
Answer C Explanation	[[AnswerCExp::Post-cardiac injury pericarditis, also known as post-myocardial infarction pericarditis has similar clinical presentation, but it occurs 2-4 days following an MI. The pathophysiology is thought to be of autoimmune origin due to a reaction to the myocardial neo-antigens.]]
Answer D	AnswerD::Dressler’s syndrome
Answer D Explanation	[[AnswerDExp::This patient is returning to the office due to Dressler syndrome, which is a post myocardial infarction syndrome. It is a form of pericarditis that occurs in the setting of injury to the heart (myocardial infarction). Typically, it occurs 2 to 10 weeks following a myocardial infarction.]]
Answer E	AnswerE::Aortic dissection
Answer E Explanation	[[AnswerEExp::The history of MI suggests that myocardial infarction is the inciting factor for the pericarditis.]]
Right Answer	RightAnswer::D
Explanation	[[Explanation::This patient is returning to the office due to Dressler syndrome, which is a post myocardial infarction syndrome. It is a form of pericarditis that occurs in the setting of injury to the heart (myocardial infarction). Typically, it occurs 2 to 10 weeks following a myocardial infarction. Acute pericarditis presents between 6 weeks to 6 months of the disease onset. Acute pericarditis is more common than chronic pericarditis, and often occurs as a complication of viral infections, immunologic conditions, or as a result of a heart attack (myocardial infarction). Subacute pericarditis presents within 6 weeks to 6 months of the disease onset Chronic pericarditis manifests after 6 months of the disease onset. Chronic pericarditis is less common. It may manifest as scarring of the pericardium, which is a condition known as constrictive pericarditis. Educational Objective: Dressler syndrome is a form of pericarditis that presents 2 to 10 weeks following a myocardial infarction. The symptoms of pericarditis include: retrosternal chest pain aggravated when lying down and alleviated by sitting up. The EKG may show diffuse ST segment elevations and PR interval depression. References: Master the Boards for Step 2CK page 54 Read more here: http://www.ncbi.nlm.nih.gov/pubmed/20194155]]
Approved	Approved::Yes
Keyword	WBRKeyword::MI, WBRKeyword::Pericarditis, WBRKeyword::Chest pain
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::