Medical Image of the Week: Focal Myopericarditis

Figure 1. Transverse view (panel A) and longitudinal view (panel B) of MRI with gadolinium enhanced contrast of chest showing abnormal enhancement at the level of the cardiac apex and also at the mid aspect of the infero-lateral wall and near the cardiac base within the lateral wall, consistent with the clinically suspected diagnosis of focal myopericarditis.

A 44-year-old man with no significant past medical history was admitted with a history of two episodes of substernal chest pain unrelated to exertion which had resolved spontaneously. Admission vital signs were within normal limits and physical examination was unremarkable. Basic lab tests were normal and urine toxicology was negative. Electrocardiogram was unremarkable with no ST/T changes. Troponin I was elevated at 4.19 which trended up to 6.57. An urgent cardiac angiogram was done which revealed normal patent coronaries. His transthoracic echocardiogram was also reported to be normal. He continued to have intermittent episodes of chest pain that was partially relieved by morphine. Erythrocyte sedimentation rate and C-reactive protein were elevated. Work up for autoimmune diseases, vasculitis, myocarditis panel were insignificant. Later, magnetic resonance imaging (MRI) with gadolinium enhanced contrast (Figure 1) was obtained which showed abnormal epicardial/subepicardial myocardial enhancement within the inferolateral wall and cardiac apex consistent with focal myopericarditis. He was started on Ibuprofen and colchicine. His chest pain significantly improved and he is currently following up as an outpatient.

Acute myo-pericarditis is primarily a pericarditic syndrome with variable myocardial involvement which is usually seen in male adolescents (1,2). There are 3 main etiologic categories: idiopathic, infectious or immune mediated. Patients present with chest pain that is sharp in nature with gradual onset radiating to the interscapular region, increasing with inspiration and easing with leaning forward. Pericardial friction rub on physical exam is considered pathognomonic. A typical pattern of ECG evolution includes diffuse ST segment elevation and PR depression, followed by normalization of ST and PR segments and then diffuse T wave inversion. Troponin I levels may be elevated, provides a rough estimate of the extent of myocardial inflammation. Cardiac MRI with gadolinium contrast is the best imaging modality to define the extent of myocardial involvement and patency of coronary system which is not always readily available. Therapy of choice is aspirin (1-1.5 g/day as mean dose) or nonsteroidal anti-inflammatory drugs such as ibuprofen for 7-10 days until symptom resolution. Colchicine should be the initial therapy in all refractory cases and in recurrent pericarditis. Physical exercise is contraindicated for at least 6 months from the onset of illness.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD, and Venu Ganipisetti MD

Department of Internal Medicine,

Presence Saint Francis Hospital

Evanston, IL USA

References

1. Imazio M, Cooper LT. Management of myopericarditis. Expert Rev Cardiovasc Ther. 2013;11(2):193-201. [CrossRef] [PubMed]
2. Sharma J, Fernandes N, Alvarez D, Khanna S.Acute myopericarditis in an adolescent mimicking acute myocardial infarction. Pediatr Emerg Care. 2015;31(6):427-30. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: focal myopericaditis. Southwest J Pulm Crit Care. 2015;11(1):47-8. doi: http://dx.doi.org/10.13175/swjpcc064-15 PDF

Medical Image of the Week: Boerhaave's Syndrome During Colonoscopy

Figure 1. Chest X ray showing bilateral subcutaneous emphysema extending from the supraclavicular area and above to the neck.

Figure 2. Video of representative coronal views of the thoracic CT scan showing subcutaneous emphysema in the supraclavicular area and neck.

Figure 3. Fluoroscopic esophagram revealing a focus of oral contrast actively extravasating (white arrow) approximately at 2.5 cm above the gastro-esophageal junction consistent with a small perforation.

A 76-year-old woman with no significant past medical history underwent outpatient screening colonoscopy. The procedure was difficult due to a tortuous colon and only multiple diverticula were visualized. She vomited once during the procedure. In the immediate postoperative period, she complained of neck swelling. Her vital signs were stable. On examination, right sided neck and facial swelling with palpable crepitations were noticed as well as coarse breath sounds heard on auscultation of both lung fields. Immediate chest X-ray (Figure 1) was obtained which showed bilateral subcutaneous emphysema extending from the supraclavicular area and above to the neck. Subsequent thoracic CT scan showed extensive subcutaneous air within the soft tissues of the neck bilaterally, extending into the mediastinum and along the anterior chest wall (Figure 2). An esophagram (Figure 3) revealed a focus of oral contrast actively extravasating approximately at 2.5 cm above the gastro-esophageal junction consistent with a small perforation. She underwent left thoracotomy with esophageal repair. Further hospital course was uncomplicated and she was discharged to a sub-acute rehabilitation facility. 

Boerhaave's syndrome is a spontaneous perforation of the esophagus due to sudden increase in intra-esophageal pressure combined with negative intrathoracic pressure caused by straining or vomiting (1). The tear usually occurs at the left posterolateral wall of the lower third of the esophagus. Usually patients have severe retching and vomiting which is followed by excruciating retrosternal chest and upper abdominal pain after perforation. Other manifestations are odynophagia, tachypnea, dyspnea, fever, and shock. On physical examination subcutaneous emphysema (crepitation) is an important diagnostic feature. Chest radiograph usually reveals mediastinal or free peritoneal air as the initial manifestation, and hours to days later pleural effusion with or without pneumothorax, widened mediastinum, and subcutaneous emphysema are typically seen. The diagnosis of esophageal perforation can also be confirmed by water-soluble contrast esophagram using Gastrograffin, which reveals the location and extent of extravasation of contrast. Treatment depends upon the size and location of the perforation. Surgery is generally required for thoracic perforations while cervical perforations can often be managed conservatively with continuous nasogastric suction, intravenous broad-spectrum antibiotics, and parenteral nutrition.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD and Venu Ganipisetti MD

Department of Internal Medicine

Presence Saint Francis Hospital

Evanston, IL USA

Reference

1. Nirula R. Esophageal perforation. Surg Clin North Am. 2014;94(1):35-41. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: Boerhaave's syndrome during colonoscopy. Southwest J Pulm Crit Care. 2015;11(1):42-44. doi: http://dx.doi.org/10.13175/swjpcc058-15 PDF