39 year old male CC: "Sick"

Here’s another great case courtesy of Mike from Massachusetts.

EMS is dispatched to a large health clinic affiliated with a local university, for the “sick male.” Initial dispatch is an ALS ambulance, ALS rescue company, and BLS engine company. Rescue company and engine company are canceled on ambulance’s arrival.

Upon arriving on scene, we find a 39-year-old male patient seated upright on an examination bench. He is alert and oriented x4, with slightly moist and warm skin, otherwise appearing free of distress.

He describes coming to the doctor’s today to be seen for a “malaise” and mild fever he had been experiencing over the past two weeks (100.2 F, taken at the office).

While being interviewed by the physician, he casually mentioned that he had been experiencing occasional episodes of “sharp” pain in his chest, the last episode a week ago and when he laid down for bed. A 12-lead ECG was obtained by the physician, and she reports having concern about “near global ST elevation.” This prompted EMS activation.

Patient has no significant past medical history, takes no medications, and has no medication allergies. He denies any recent history of trauma or infectious exposures that he can recall.

The cardiac monitor is applied, showing sinus rhythm @ 54 bpm. Patient is placed on oxygen by nasal cannula. Vital signs are obtained:

  • Blood pressure: 136 / 64
  • Heart rate: 58 bpm
  • Respiratory rate: 16
  • Temperature (oral): 100.2 F

While assessing lung sounds, patient takes a deep breath, noticably flinches and states, “There it is again.” He describes the sharp pain (localized in the sub-sternum) that he previously reported to the physician, which resolves shortly after. His lung sounds are clear and equal bilaterally, and this is reproducable with subsequent deep breaths.

IV access and a 12-lead ECG are obtained.

Patient is assisted onto stretcher without incident, moved to ambulance. Patient is transported to the hospital of the university’s preference, which is also a level 1 trauma center (< 10 minute transport time).

What do you think of the ECG?

See also:

39 year old male CC: “Sick” – Discussion (pericarditis)

24 Comments

  • Bob says:

    Benign early repolarization. Sharp chest pain on inspiration with low grade fever? My guess is PE.

  • Stephen says:

    Pericarditis

  • Troy says:

    I don’t think its pericarditis because there’s no global STE. What worries me is the elevation in V5,V6 with depression in III. PE is a definite possibility as well with the low grade fever but usually is a constant pain. I would also check to see if the substernal CP is reproducible when pressing on the intercostal margin of the sternum to see if costochondritis is a possibility. Also endocarditis is also a possibility. Id order a BMP, CBC w/ diff, Troponin I/CK-MB, D-dimer,Sed-rate, Blood cultures, serial EKG’s, CXR, and possibly MRI (to look at the valves) if strep came back positive. Of course, my treatment would change based on my blood work results. IV, O2, Monitor en-route.

  • Christopher says:

    Pericarditis and pleurisy are top on my list. Potential PR depression in II and III with minimal (if any) PR elevation in aVR. Looks more like BER than Pericarditis however. Maybe he has a pleural efflusion that is causing some pain on inspiration? PE makes the list if only for Q3T3 and some other T wave changes with pain on respiration. His heart rate though doesn’t suggest much compensation (tiny PE?).

    Calm, comfortable ride to the closest facility with our standard fare of O2, IV, monitor.

    Definitely a case which highlights how suggestive the ECG can but ultimately non-diagnostic.

  • NYCMedic says:

    Pericarditis/myocarditis definitely tops my list. I’m not sure why Troy says there is no global STE, I definitely see elevations in nearly every lead except V1/aVR. Also, for pericarditis, elevations in every lead is not a requirement, only really needs “diffuse” elevations, which this has. There is notching (Rr’) in every lead but V1, suggestive of pericarditis and BER. PR segment depression can be seen in all leads except aVR/V1, most pronounced in II. The ST segments are scooped and upwardly concave in I, II, aVL, aVF, and V2-V6.

    Finally, the clinical history fits pericarditis/myocarditis best with this ECG. He noticed especially sharp pain when he laid down for bed, AND during deep inspiration. PE is low on my list. Like Christopher said, the ECG does not have an S1Q3T3 pattern (and I only see Q3, I believe the T wave in III is biphasic, not inverted if you look at the 2nd complex). The patient is not tachycardic, not in respiratory distress, no hemoptysis, nothing listed about suspicion for/past DVT, no recent surgery, and he is relatively young. The only symptom that would fit PE criteria is pleuritic pain. Pleuritis would be second in my differential, but the patient isn’t coughing, and I don’t think pleuritis is worsened while being supine.

    If patient remains eupneic with a good SpO2, then TXP to hospital of choice, establish IV access and serial 12-lead enroute, and position of comfort.

  • Dave B says:

    Christopher, i am with you on the pericarditis… patient presentation seems to favor it…
    as for the ECG, global ST elevation, no reciprocal changes, ST elevation in I and II also suggest pericarditis, as do the notched QRS.

  • Brandon O says:

    Another vote for pericarditis, with BER (probably with an unrelated concomitant infection) and PE a distant second and third. NYCMedic’s analysis is spot on. Diffuse ST elevation, with ST depression in V1 and aVR, BER-like morphology, PR depression, fever, sharp and pleuritic chest pain exacerbated when prone — all pretty classic.

    My only questions/concerns: the flattened ST depression in III; the early precordial transition; the borderline wide QRS; and the oddly delta-wave-like precordials (check out V3). Any thoughts on these?

  • Troy says:

    I apologize…. After re-evaluating the 12 lead (not on my phone and with some caffiene in me) the only leads that don’t have STE are III, aVR, and V1 which is consistant with pericarditis. Please forgive me!

  • Brandon O says:

    Bad Troy! No soup for you!

  • Troy says:

    But my DDx’s still stand. -_-

  • VinceD says:

    Anyone else possible preexcitation? Even with a normal PR, 118ms is a pretty wide QRS for someone who’s only 38 with no cardiac Hx, plus aVL and V3 seem to take their time reaching the nadir of their QRS. I think I’ve heard a q in V6 make preexcitation very unlikely, but it’s something to consider and it’d at least get me to ask if he’s ever had palpitations or a fast heart rate in the past. It’s almost certainly unrelated to his current symptoms, but it’d be an interesting pickup.
    Dealing with the reason for his visit to the clinic; while the Hx fits possible pericarditis, I’m unconvinced the ECG is diagnostic and leaning towards early-repole, although it’s still in my mind. No signs of PE. Costochondritis is also a high on my differential, I’ve had it and it’s a pain.

  • sdfsda says:

    J point elevation suggestive of BER.

  • NYCMedic says:

    Brandon/Vince both mention either a “delta-wave” like R-wave or an “extended nadir” with borderline wide-QRS. My interpretation of this is that this is a late intrinsicoid deflection (beginning of QRS to peak of the R wave > 0.05 seconds) as a result of LVH (criteria is met in lead I w/QRS >=12mm, with further evidence in aVF, along with LAE seen as p-mitrale in lead II and biphasic P in V1).

    Vince, why are you leaning towards BER when you say the patient’s Hx and S/S fit pericarditis? What aspect of the ECG do you feel don’t meet pericarditis criterion? Also, could you explain further why costochondritis is “high” on your ddx? Yes, it will have pain on inspiration, but this patient c/o substernal pain, not rib pain (assuming we can trust the history given in this case), denies trauma/infection and more significantly I think is pain when lying supine. Finally, I don’t think is a benign ECG, and we would definitely have to r/o a cardiac cause before moving onto musculoskeletal.

  • Troy says:

    Heart tones would be useful. If you hear a friction rub it would help with the diagnosis. Plus ASA is one of the treatments for pericarditis anyways

  • VinceD says:

    NYCMedic, good call on the LVH criteria (whether or not he actually has anatomical hypertrophy) probably causing the wide QRS and slurring. That’s much more likely than WPW in such a case, unless it was some sort of atypical preexcitation causing a wide/big QRS. Once again, unlikely, but this is a blog of unusual cases, so maybe Tom got his hands on one…

    As for why I was leaning towards BER; I think it’s probably just a case of me being blase towards pericarditis. Sure, it’s a common part of our differential in every ECG with ST-elevation (it’s probably listed in the comments section of every case on this site), but we just don’t really see it that often: I believe it accounts for something like 1% of ST-elevation. I was rushing out the door before and skimmed through the S/S, so my read was based mostly off the isolated ECG, but now realize that his history pretty much fits pericarditis to a T clinically.
    Maybe it’s the combination of the large R waves with relatively small amounts of ST-elevation in a patient who, in my imagination, is otherwise healthy, somewhat thin, and fit appearing, that makes me think this is what his ECG always looks like. Clinically, there’s a good chance he has pericarditis and that warrants further testing/treatment, but we see a lot of ECG’s just like this one in healthy folks, so I’m not convinced this piece of paper is changing the likelihood of pericarditis in my mind, which is somewhat high anyway. I’d give this ECG an imaginary likelihood ratio of 1.2 for pericarditis. With that said, he’s still getting a full workup and aspirin on the way in.

    I didn’t do a good job conveying my meaning before when I said costo was “high” on my differential. It’s not my likely diagnosis, but since common entities are common and rare ones are rare, it has to stay in my mind for now and I’d at least do some poking and provoking to gather some more info. Plus, from experience, I know costo can cause midsternal pain (not quite retrosternal though) and is very positional. Of course I’m biased from my experience (aren’t we all), but it’s still useful.

    I hope Tom has a baseline ECG, cause my money’s on the unlikely scenario of this being baseline for the guy, even if he does have a confirmed diagnosis of pericarditis. Good thing I like being wrong sometimes to help cement these cases in my memory.

  • NYCMedic says:

    VinceD, thanks for the thoughtful reply, I understand where you are coming from. I think we have to be careful not to dismiss something though simply because we are so used to seeing “abnormal” ECG’s that turn out to be benign, otherwise we run the risk of thinking everyone is “not legit” except in the most extreme cases. I am very interested in the conclusion to this case.

  • Brandon O says:

    I just want to add that the pericarditis/BER distinction, although physiologically meaningful, may be a clinically imaginary one prehospitally. The two generally have VERY similar ECG presentations, and what’s the effect on our care either way? Okay, they each have some unique methods of ruling against MI (for instance, PR depression for pericarditis, R wave amplitude for BER), but even if we use them all MI seems pretty unlikely here. I suppose pericarditis would raise our clinical concern for a developing tamponade, but a sudden onset would be pretty phenomenal. We asked the right questions to get pericarditis-pertinent hx, I think we’ve done our due diligence as far as this corner of the differential. (As Troy mentions, auscultation could add a bit more, if you’re good with your murmurs.)

    That said, there are enough “hmm” datapoints here that, like NYCMedic, I’m curious about the final word. (To the notable points I mentioned, there’s also the borderline bradycardia.) And if you’re right about the marginal LVH — based on a late intrinsicoid deflection and barely-LAE — I’ll buy you a beer, that’s a hell of a call.

  • Christopher says:

    Brandon, I saw the “delta”/delayed intrinsicoid but ignored it with the normal PRi. Given his age and Hx I put LVH way down on my list too. I figured that was some sort of “normal variant”.

  • Ches says:

    Pericarditis hands down. Here is why:
    1) PR depression,
    2) Diffuse ST elevation,
    3) Scooping, upwardly concave ST segments, and
    4) and notching of the end of the qRs.

    Remember, not all of these points have to be present in every single lead. These criteria which are present are about 80% of the information needed for diagnosis of pericarditis. The other 20% is the patient exam and Hx of present illness. For example, pain is worse at night when supine which is typical of pericarditis. Also, “sharp” CP upon deep inspiration. This is indicative of pericarditis due to the fact that deep inspiration expands the lungs, increasing pressure against the heart by increasing intrathoracic pressure and irritating the pericardium. The patient also has a low-grade fever can be indicative of pericarditis. Not to mention the QTc interval is only 395ms which does not fit the typical criterium of at least 425ms QTc as seen in cath lab confirmed STEMI patients. To get further confirmation for the pericarditis though, I would ask the patient if he has any pain when he swallows, and in a sitting position does leaning forward relieve the pain at all. If he does answer yes to these questions then this would further confirm the Dx of pericarditis. I would, however, not be so dumb as to not perform serial EKGs, check cardiac enzymes, and d-dymer to R/O an MI or PE. But notice the patient is not SOB and does not have any N/V, which further points towards pericarditis.

  • NICE POST Tom! – with LOTS of neat teaching points.

    The history is highly suggestive of acute pericarditis. Given this history – to me the ECG is virtually diagnostic. Clearly one can’t rule out some underlying component of ERP (Early Repolarization Pattern) – esp. without benefit of a baseline ECG … and given J-point notching in multiple leads . – but I see upward concavity ST elevation in virtually all leads except the 3 “right-sided” ones (ie, leads III, aVR and V1) – and that is highly typical for Stage I acute pericarditis.

    Supporting the diagnosis of acute pericarditis are: i) Lead I ST segment looking like lead II (vs leads II and III looking similar as is usual for acute inf. MI); ii) PR depression in a number of leads (subtle but real); iii) PR elevation in lead aVR (hard to say how much of what we see in aVR is ST depression vs PR elevation vs some combination thereof); iv) no more than small q waves (which are common as a baseline); and v) lack of any reciprocal ST depression.

    The concept of “smiley-shaped” ST elevation (which I popularized in my textbooks several decades ago) is worthy of mention. It’s a GREAT visual aid – but you may want to describe upward concavity or ST coving (downward convexity) to your consulting cardiologist (rather than “smiley” or “frowny”) so as to enhance your credibility. But “smiley” vs “frowny” ST segments works as a great descriptor among colleagues.

    Great teaching points about WPW! – and how the normal septal q waves makes this unlikely despite lead V3’s appearance. In general – one should see delta waves in more than just a single lead. That said – I’ll add 2 points: i) You CAN have WPW with a normal PR (ie, you have baseline 1st degree before you hook into the AP [accessory pathway] connection); and ii) The ECG of a patient with accessory pathways is not always “fixed” – but instead you may have all AP conduction (yielding consistent delta waves) – all normal conducted (‘concealed AP’) – or conduction down normal and/or AP alternating with varying relative degree of conduction down one pathway or the other.

    Finally – Why the IV antibiotics for an “unknown infection”? Acute pericarditis is most often viral – as the patient would be a whole LOT sicker if this was acute bacterial pericarditis … I understand the treating physicians may have wanted to “cover things” – and we may not know the full story – but I’m skeptical about the indication for antibiotics that may cloud the issue given presumptive acute viral pericarditis …

    BOTTOM LINE: Great case Tom! Thanks for posting – : )

  • Sue says:

    CT of the heart and chest.  Enlarged thymus maybe.Congential heart condition undiagnosed.
     

  • Ade says:

    I agree with some of the others and I am on the same page with pericarditis being my first Dx, for the following reasons:
    1. Diffuse ST elevation
    2. The ST elevation is of a concave nature sloping upward. It’s not flat or convex as this would push towards STEMI
    3. The elevation in III III
    Everything to me says pericarditis when you add in the Hx and the obs presented with
    It would be great to hear a rub on auscultation

  • Ade says:

    Loads missed out from my comment for some reason but you get the general idea

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