Chest Pain - Case 14-2: 15-Year-Old Boy
I. History of Present Illness
A 15-year-old boy was well until 1 week before presentation. At that time, he
developed the acute onset of chest pain accompanied by fever and chills. He
described the pain as sharp and intermittent. It was midsternal and did not
radiate. The pain did not increase with exertion but was worse while lying
supine or with subtle movement. He denied any syncope, shortness of breath, or
diaphoresis. He did not have night sweats, cough, or weight loss.
II. Past Medical History
He had no significant past medical history. He had emigrated from Liberia 6
weeks before his presentation. He had received bacille Calmette-Gu
érin immunization 5 years earlier and was noted to have a 12-mm induration after
tuberculin PPD (purified protein derivative) skin testing on arrival in the
United States.
III. Physical Examination
T, 36.8°C; RR, 24/min; HR, 80 bpm; BP, 111/64 mm Hg
Weight, 25th to 50th percentile
In general, he was a thin adolescent boy in no acute distress. His cardiac
examination revealed normal first and second heart sounds (S1 and S2,
respectively), with a regular rate and rhythm. No cardiac murmur was
appreciated. His chest examination demonstrated clear breath sounds
bilaterally. The liver edge was minimally palpated just below the right costal
margin. The remainder of his physical examination was within normal limits.
IV. Diagnostic Studies
The complete blood count revealed 6,800 WBCs/mm3. The hemoglobin was 12.8 g/dL, and the platelet count was 426,000/mm3. Serum electrolytes, blood urea nitrogen, and creatinine were normal. Calcium,
albumin, AST, alkaline phosphatase, total bilirubin, and prothrombin and
partial thromboplastin times were also normal. Lactate dehydrogenase was
elevated at 904 U/L. A chest roentgenogram was initially interpreted as normal.
V. Course of Illness
The patient was discharged home with ibuprofen for his chest pain. The chest
roentgenogram was reviewed the following day, and the revised interpretation
indicated cardiomegaly, suggesting a diagnostic category for his chest pain.
Computed tomography (CT) of the chest and abdomen also revealed bilateral
nodular pulmonary infiltrates and splenomegaly. The specific cause of his chest
pain was determined by pericardial biopsy.
Discussion: Case 14-2
I. Differential Diagnosis
Chest pain in an adolescent boy is rarely life-threatening. However, a careful
history and physical examination must be undertaken to determine which cases
require further investigations.
The majority of cases of chest pain in childhood are classified as idiopathic.
Adolescents are more likely to have psychogenic causes for their chest pain
than younger children, with this diagnosis being more common in girls.
Musculoskeletal causes are quite common, including muscle strain, trauma, and
costochondritis. Other common causes are cough, asthma, and pneumonia. Less
commonly, chest pain in adolescents is caused by gastroesophageal reflux,
pneumothorax, pneumomediastinum, or pleural effusion. In an adolescent with
chest pain, it is important to inquire about tobacco, cocaine, and
methamphetamine use, all of which can be associated with chest pain. In
adolescent girls, one should consider pubertal breast development or
fibrocystic breast disease, and in boys, gynecomastia. Rarely, but importantly,
one should consider cardiovascular causes of chest pain, including structural
diseases (e.g., idiopathic hypertrophic cardiomyopathy), coronary artery
disease, myocarditis, pericarditis, and arrhythmias.
The features of this case that warrant further evaluation include the acute
onset of the chest pain and the variability with positional changes.
II. Diagnosis
The chest roentgenogram revealed cardiomegaly. An echocardiogram demonstrated a
10-mm circumferential pericardial effusion with nodular areas noted alongside
the myocardial surface. Electrocardiography (ECG) revealed ST elevation. A
repeat PPD test demonstrated a 19-mm area of induration. The patient underwent
pericardial window placement with pericardial biopsy. Stains of pericardial
fluid were negative for acid-fast bacilli, but microscopic examination of the
pericardial tissue revealed numerous granulomas, and acid-fast smear of the
tissue demonstrated organisms.
Mycobacterium tuberculosis was detected from culture of the pericardial tissue 12 days after inoculation. The diagnosis is tuberculous pericarditis. He was treated with isoniazid, rifampin, pyrazinamide, and ethambutol.
Sputum was acid-fast stain and acid-fast culture negative. His family refused
human immunodeficiency virus (HIV) testing. He was ultimately discharged home
to complete his treatment under directly observed therapy.
III. Incidence and Epidemiology
M. tuberculosis infections are the most frequent cause of deaths worldwide from a single
infectious organism. Approximately one third of the world
's population has been infected with M. tuberculosis. Usually, infection occurs through inhalation of droplet nuclei and causes
pulmonary infections. The HIV epidemic has significantly increased the
infection rate worldwide.
Pericarditis may result from infectious or noninfectious causes (Table 14-4).
Pericarditis, an uncommon complication of tuberculosis infection, can be fatal
even with proper diagnosis and treatment. Tuberculous pericarditis occurs by
extension of an adjacent focus of infection, such as mediastinal or hilar
nodes, lung, spine, or sternum. It occurs less commonly in association with
miliary tuberculosis.
Tuberculous pericarditis is believed to occur in 0.4% to 4% of children with
tuberculosis. The prevalence of tuberculosis varies by geographic region. Its
relationship to HIV disease is well known. In many African countries where
tuberculosis and HIV are endemic, pericarditis in an HIV-positive patient is
considered to be tuberculosis until proved otherwise.
IV. Clinical Presentation
The presentation of pericarditis varies depending on the cause. The pain
associated with pericarditis is often retrosternal, radiating to the shoulder
and neck. The pain is typically worsened by deep breathing, swallowing, and
supine positioning. Tuberculous pericarditis can have both acute and insidious
presentations. The most common symptoms are cough, dyspnea, and chest pain.
Other associated symptoms include night sweats, orthopnea, weight loss, and
edema. Physical examination may reveal fever, tachycardia, and pericardial rub.
Pulsus paradoxus, hepatomegaly, pleural effusions, and muffled heart sounds are
often associated with the condition.
V. Diagnostic Approach
The diagnosis of pericarditis is straightforward, but establishing M. tuberculosis as the etiologic agent is more challenging.
Tuberculin skin test. A positive skin test increases the suspicion for tuberculous pericarditis, but a
negative skin test does not eliminate the diagnosis.
Chest roentgenogram. Chest radiography reveals cardiomegaly due to pericarditis and pericardial
effusions. Approximately 40% of patients with tuberculous pericarditis have an
associated pleural effusion. Patients with tuberculous pericarditis may also
have findings suggestive of pulmonary or miliary tuberculosis.
Electrocardiogram. The ECG is abnormal in most cases of pericarditis, reflecting pericardial
inflammation. ST-segment elevations develop early in the illness. Large
pericardial effusions are associated with reduced QRS voltage.
Echocardiogram. Echocardiography detects associated pericardial effusions and pericardial
thickening. Patients with tuberculous pericarditis may have nodular densities
along the pericardium.
Pericardiocentesis and pericardial biopsy. Acid-fast stains of pericardial fluid are often negative, but pericardial fluid
cultures are positive for
M. tuberculosis in approximately 50% of cases. Polymerase chain reaction testing to detect M. tuberculosis has been attempted, but the reliability of this test in pericardial fluid
specimens is not clear. Granulomas detected on microscopic examination of
pericardial tissue strongly suggest the diagnosis of tuberculous pericarditis.
Pericardial tissue is usually acid-fast stain and culture positive and is
considered critical to confirming the diagnosis. The most accurate results are
obtained if the pericardial tissue sample is acquired before the start of
antituberculosis therapy.
Human immunodeficiency virus test. Due to the close association between HIV and tuberculous pericarditis, HIV
testing should be performed in all patients diagnosed with tuberculous
pericarditis.
VI. Treatment
If the patient has hemodynamic compromise, pericardiocentesis is indicated.
Certainly, in cases of tamponade this is necessary. A second option for
drainage is an open surgical procedure, which allows for removal of the
pericardial fluid as well as obtaining pericardial tissue for culture and
histopathologic studies. Controversy does exist as to whether
pericardiocentesis or open drainage should be the procedure of choice in
uncomplicated cases of suspected tuberculous pericarditis. Either way, one must
strive to prevent the formation of a constrictive pericarditis.
Antibiotic therapy consists of the same regimens as are prescribed for pulmonary
tuberculosis. Adjuvant corticosteroid therapy appears to decrease the amount of
effusion and reaccumulation of pericardial fluid, reducing the need for
repeated interventions.
VII. References
1. Dooley DP, Carpenter JL, Rademacher S. Adjunctive corticosteroid therapy for
tuberculosis: a critical reappraisal of the literature.
Clin Infect Dis 1997;25:872–877.
2. Gewitz MH, Vetter VL. Cardiac emergencies. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine, 4th ed. Baltimore: Lippincott Williams & Wilkins, 2000:659–700.
3. Haas DW. Mycobacterium tuberculosis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's principles and practice of infectious diseases, 5th ed. Philadelphia: Churchill Livingstone, 2000:2576–2604.
4. Starke JR. Tuberculosis. In: McMillan JA, DeAngelis CD, Feigin RD, et al.,
eds.
Oski's pediatrics: principles and practice, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 1999:1026–1039.
5. Trautner BW, Darouiche RO. Tuberculous pericarditis: optimal diagnosis and
management.
Clin Infect Dis 2001;33:954–961.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Chest pain
» Next page: Chest Pain - Case 14-3: 20-Year-Old Boy (Pediatric Complaints and Diagnostic Dilemmas)
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