salicylates and Chest-Pain

A 28-year-old man with extensive travel history to developing countries was hospitalised for intermittent sharp chest pains, worst when supine and with inspiration. Two weeks prior to presentation, he had suffered a flu-like illness with a sore throat, which was resolving. Physical examination was notable for mild fever and tachycardia with cervical lymphadenopathy and painful bilateral knee and wrist effusions. Cardiac auscultation was remarkable for a soft early-peaking systolic murmur over the aortic area with a decrescendo early diastolic murmur along the left sternal edge. There was mild leucocytosis, elevation of serum troponin and acute-phase reactants with an ECG showing sinus tachycardia. Echocardiographic windows were extremely limited but suggested the presence of pericardial effusion and aortic regurgitation. Cardiac MRI was performed (figure 1). Viral, microbiological and autoimmune testing was remarkable only for significant elevation of antistreptolysin-O titres (1450 IU rising to 1940 IU, normal <200 IU). Pericardiocentesis revealed an exudative effusion, which was negative by cytology and microbiological analysis, including for tuberculosis and fungi.. The most appropriate next step is? Coronary angiographyEndomyocardial biopsyTreatment with colchicine for 3 monthsTreatment with corticosteroidsTreatment with high-dose salicylates and long-term penicillinFor the answer see page 808For the question see page 769.

Topics: Adult; Anti-Bacterial Agents; Anti-Inflammatory Agents, Non-Steroidal; Arthralgia; Chest Pain; Drug Administration Schedule; Humans; Magnetic Resonance Imaging, Cine; Male; Penicillins; Pericardial Effusion; Rheumatic Heart Disease; Salicylates; Time Factors; Treatment Outcome

A 23-year-old male patient, with a diagnosed mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes, was referred for recurrent fainting. Long sinus pauses were documented, and an atrial pacemaker with an active-fixation lead was implanted. He was admitted again 4 months later because of chest pain and diffuse ST segment changes. On the basis of these, pericarditis was diagnosed, corticosteroid therapy and the adjunct of salicylates were started, which in few hours enabled the relief of symptoms and the reduction of ECG abnormalities. However, 24 h later, the patient suddenly experienced severe hypotension and tachycardia, and an emergency echocardiogram showed pericardial tamponade. The differential diagnoses with atrial free-wall perforation and Dressler-like syndrome were discussed, along with the difficulties in management. By a 'wait and see' strategy, the active-fixation atrial lead was eventually changed into a passive-fixation one, while continuing corticosteroids and salicylates. The patient quickly improved and is now, after 1 year, symptom free. For the explanation of any phenomenon, it is important that as few assumptions as possible are considered, eliminating those that make no difference in the observable predictions of the explanatory hypothesis or theory, according to the concept of Ockham's razor.

Topics: Adrenal Cortex Hormones; Anti-Inflammatory Agents; Cardiac Pacing, Artificial; Cardiac Tamponade; Chest Pain; Device Removal; Diagnosis, Differential; Echocardiography; Electrocardiography; Equipment Design; Humans; Male; MELAS Syndrome; Pacemaker, Artificial; Pericardiocentesis; Pericarditis; Recurrence; Salicylates; Syncope; Treatment Outcome; Young Adult