Be Still Thy Beating Heart

1NSLIJ Lenox Hill Hospital, New York, NY

Meeting: Hospital Medicine 2015, March 29-April 1, National Harbor, Md.

Abstract number: 641

Keywords:

Case Presentation: A 36 year-old-male with a history of seizure disorder presented to the hospital with high-grade fevers, chest pain, and sore throat. At the time of presentation, he had a fever of 38.3°C, a heart rate of 120 beats per minute, and pleuritic chest pain. Laboratory data showed rising troponins and elevated inflammatory markers (WBC of 41, ESR of 81 mm, and CRP of 21 mg/dL). ECG was significant for sinus tachycardia with diffuse ST elevation. The echocardiogram revealed a moderate pericardial effusion. The patient was initially started on colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs) for presumed myopericarditis, with intractable symptoms. For the next five days, he continued to have arthralgias and high grade fevers to 40°C, with negative blood and viral cultures.  An extensive workup including a whole body nuclear and computed tomography (CT) scan were performed. The unit physicians failed to identify an infectious or malignant source. Additional laboratory values revealed a very high ferritin level (15993 ng/mL), a negative antinuclear antibody (ANA) and rheumatoid factor (RF). The care team’s working diagnosis was adult-onset Still’s disease (AOSD). Corticosteroids followed by interleukin-1 receptor antagonist (anakinra) therapy were started,  and the patient rapidly improved. At a 10 day outpatient follow up, his symptoms had resolved.

Discussion: Myopericarditis is a rare manifestation of AOSD and may result in cardiac failure or arrhythmia1. The diagnosis is one of exclusion and requires a strong clinical suspicion.  Our patient met Yamaguchi’s criteria for diagnosis of AOSD, including fever, arthralgias, sore throat, leukocytosis and a negative ANA and RF2. Myopericarditis in the setting of AOSD is often resistant to the usual treatment of colchicine and NSAIDs. Steroids, however, are the mainstay of treatment.  In resistant cases, the patient may require immunosuppressants, disease modifying agents, or intravenous immunoglobulins.

Conclusions: This clinical vignette demonstrates that AOSD should be considered as an etiology of myopericarditis. Complications can be life threatening and early treatment will impact survival.

References:

1.JadhaV P, Nanayakkara N. “Myocarditis in adult onset stills disease”. International Journal of Rheumatic Diseases 12 (2009): 272–274.


2.Yamaguchi M, Ohta A, Tsunematsu T, Kasukawa R, Mizushima Y, Kashiwagi H, Kashiwazaki S, Tanimoto K, Matsumoto Y, Ota T; Ohta; Tsunematsu; Kasukawa; Mizushima; Kashiwagi; Kashiwazaki; Tanimoto; Matsumoto; Ota. “Preliminary criteria for classification of adult Still’s disease”. J. Rheumatol 19 (1992): 424–30.

To cite this abstract:

Nocerino A, Al-Badri A, Flansbaum B. Be Still Thy Beating Heart. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 641. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/be-still-thy-beating-heart/. Accessed November 22, 2019.

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