View source for WBR0017

{{WBRQuestion
|QuestionAuthor=Raviteja Reddy Guddeti MBBS, Aarti Narayan MBBS (Reviewed by Gonzalo Romero)
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|Prompt=A-65-year old male presents to the ER due to a crushing retrosternal chest pain, which started 20 minutes ago.  Additionally, he has nausea and diaphoresis. Following 2 hours of ER arrival, percutaneous coronary intervention is performed; he recovers over the next 5 days. 6 weeks following discharge, he returns to the office due to a mild retrosternal chest pain, which is aggravated when lying flat, and relieved when sitting up.  Concomitantly, he has a mild cough and runny nose consistent with a recent upper respiratory tract infection.  Complete blood count is within normal limits.  What is the most likely diagnosis?
|Explanation=This patient is returning to the office due to [[Dressler syndrome]], which is a post myocardial infarction syndrome.  It is a form of pericarditis that occurs in the setting of injury to the heart (myocardial infarction). Typically, it occurs 2 to 10 weeks following a myocardial infarction.
* [[Acute pericarditis]] presents between 6 weeks to 6 months of the disease onset.  Acute pericarditis is more common than chronic pericarditis, and often occurs as a complication of viral infections, immunologic conditions, or as a result of a heart attack (myocardial infarction). 
* Subacute pericarditis presents within 6 weeks to 6 months of the disease onset
* Chronic pericarditis manifests after 6 months of the disease onset. Chronic pericarditis is less common. It may manifest as scarring of the pericardium, which is a condition known as constrictive pericarditis.

|AnswerA=Viral pericarditis
|AnswerAExp=Viral pericarditis caused by different virus, commonly Coxsackie B virus, Echovirus, HIV or Adenovirus.  It typically presents as an acute pericarditis. 
It is important to consider the timeline of the chest pain occurring after the MI, which is 6 weeks in this case.  The history of this patient is consistent with Dressler's syndrome. 
|AnswerB=Tuberculous pericarditis
|AnswerBExp=There is nothing else in the patient history to suggest a different form of pericarditis, and no past medical history of [[tuberculosis]].
|AnswerC=Post-cardiac injury pericarditis
|AnswerCExp=Post-cardiac injury pericarditis, also known as post-myocardial infarction pericarditis has similar clinical presentation, but it occurs 2-4 days following an MI.  The pathophysiology is thought to be of autoimmune origin due to a reaction to the myocardial neo-antigens.
|AnswerD=Dressler’s syndrome
|AnswerDExp=This patient is returning to the office due to [[Dressler syndrome]], which is a post myocardial infarction syndrome.  It is a form of pericarditis that occurs in the setting of injury to the heart (myocardial infarction). Typically, it occurs 2 to 10 weeks following a myocardial infarction.
|AnswerE=Aortic dissection
|AnswerEExp=The history of MI suggests that [[myocardial infarction]] is the inciting factor for the pericarditis.
|EducationalObjectives=[[Dressler syndrome]] is a form of pericarditis that presents 2 to 10 weeks following a myocardial infarction.  
The symptoms of pericarditis include:  retrosternal chest pain aggravated when lying down and alleviated by sitting up.  The EKG may show diffuse ST segment elevations and PR interval depression.
|References=Master the Boards for Step 2CK page 54
Read more here:  http://www.ncbi.nlm.nih.gov/pubmed/20194155
|RightAnswer=D
|WBRKeyword=MI, Pericarditis, Chest pain
|Approved=Yes
}}