A 48-year-old man presented to the emergency department of our hospital complaining of sharp substernal chest pain, fever, and chills for 3 days. He denied shortness of breath, cough, night sweats, nausea, vomiting, or diarrhea. He also denied dry eyes, dry mouth, oral ulcers, or photosensitivity. He was born in the Dominican Republic but has lived in the United States since childhood. He last travelled to the Dominican Republic 5 years before presentation but otherwise had no recent travel history. He had no sick contacts and was never incarcerated. He did report an intentional 50-lb weight loss over the past year before presentation through increased dieting and exercise.
He had no past medical or surgical history and was not taking any medications. He was not allergic to any medications. There was no significant family medical history, including malignancy, tuberculosis, or autoimmune disorders. He had an occasional alcoholic beverage on weekends but denied tobacco or illicit drug use. He lived with his wife and children and worked at a local supermarket.
Assessment
On physical examination he was febrile to 103.2°F, his blood pressure was 146/99 mm Hg, his heart rate was 100 beats per minute, and his respiratory rate was 20 breaths per minute. Cardiovascular examination was significant for normal but distant heart sounds with no murmurs, jugular venous distention, or pericardial rub. His lungs were clear, and his abdomen was soft but mildly tender in the upper epigastric region. He also had a faint erythematous rash covering his cheeks and the bridge of his nose.
His initial white blood cell count was 5400/mm3. Electrolytes, troponin, amylase, and lipase levels were all within normal limits. C-reactive protein was 202 mg/L. His chest x-ray film showed marked cardiomegaly (Figure 1). The electrocardiogram was significant for sinus tachycardia and 0.5-mm PR depression in leads I and II but no ST or T wave changes (Figure 2). An echocardiogram revealed a large circumferential pericardial effusion with evidence of tamponade physiology (Figure 3, Figure 4).
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-Panagiota Christia, MD, Jeremy Miles, MD, Ioanna Katsa, MD, Carola Maraboto, MD, Robert Faillace, MD
This article originally appeared in the November 2017 issue of The American Journal of Medicine.
