Acute benign pericarditis:

Case report

ALFRED I. GREEN, B.S., D.O.,* and OTTO M.KURSCHNER, A.B., D.O., M.Sc. (Fed), F.A.C.O.P.,Philadelphia, Pennsylvania

This condition, which is also known as nonspecific,viral, or idiopathic pericarditis, has been describedin children only recently. L2 The disease usuallyfollows an upper respiratory tract infection. Theonset is generally acute, with fever and pain. Afriction rub is usually present, but there are nosignificant murmurs. The electrocardiogram showslow voltage, elevations of the S-T segment, andT-wave inversion, which may persist for manymonths.

Real cardiac tamponade is rare. The illness lastsfor several weeks, but it is benign. It has no after-effects, but the disease may recur, even repeatedly.The treatment is symptomatic. The differential di-agnosis must exclude rheumatic fever.

Case report

A 12-year-old white boy was admitted to Metro-politan Hospital on February 11, 1957, with a chiefcomplaint of recurrent fevers, easy fatigability, andintermittent joint and muscle pains. The patientwas ambulatory and in no apparent distress.

He had had a normal birth. His mother explainedthat he occasionally choked in the early days of hislife, but there was no history of cyanosis. Thepatient had had whooping cough at age 1%, chicken-pox at age 3, and measles at age 6. He had had atonsillectomy and adenoidectomy at age 3, becauseof severe bouts of tonsillitis. During this time, hehad also suffered from numerous allergies, amongwhich were orange juice and several vegetables.From the Department of Pediatrics, Metropolitan Hospital, Phil-adelphia.°Address, 619 W. Allegheny Ave.

At age 5, the patient had complained of pain inthe left knee. No swelling, stiffness, or discolorationof this knee could be demonstrated. The pain wouldlast for several hours and then disappear, only torecur every few days. While pain was present, atemperature elevation of 100 to 101 F was noted.He had continued to have intermittent pain in hisknee for several years. In the last few years thishad very much diminished.

Within the last 3 years, however, the patient hadnoted that he was unable to participate in as muchexercise as his fellow students. He did not becomeshort of breath, and there was no orthopnea, ankleswelling, or nocturnal dyspnea. He found that hesimply got tired and was unable to run as fast orwalk as far as the other children. Three weeksprior to admission, there were elevations of tem-perature which were intermittent, but not accom-panied by any joint pains. The patient was givenpenicillin when the temperature was elevated.

On examination this boy was in no pain or acutedistress. His height was 62 inches; his weight was100 pounds; blood pressure in both arms was100/60, and blood pressure in the left leg was130/80; and pulse and respirations were withinnormal limits. Examination of the throat revealeda moderate postnasal drip, large lymphoid tabs overboth tonsillar pillars, and an injected pharynx. Thechest was symmetrical and the lungs were resonant.No abnormal sounds were present. The heart wasnormal as to size, rate, rhythm, and intensity. Nosignificant murmurs were audible. The liver andspleen were not palpable. Examination of theextremities, particularly of the joints, disclosed noabnormalities.

A complete chest x-ray study with emphasis oncardiac disorders was ordered, the results of whichwere as follows: The osseus thorax was symmetricaland showed no evidence of developmental ordestructive change. The lung fields were well

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aerated, and there was no evidence of a grossconsolidative or infiltrative process. The hilar andinterstitial pulmonary markings were average inthickness and density. The cardiac shadow wasaverage in size and contour, with preservation ofthe retrosternal and retrocardiac spaces. The ()paci-fied esophagus was average in position and contour.The mediastinal structures showed no evidence ofwidening or of displacement. The diaphragmaticdomes were smooth and regular, and the cardio-phrenic and costophrenic angles were clear.

A fluoroscopic examination demonstrated sym-metrical pulmonary aeration with no abnormalmediastinal shift. Diaphragmatic excursions werewithin average limits. The cardiac rhythm wasregular, and cardiac pulsations appeared to besomewhat more rapid than average and the ampli-tude of the pulsations was increased.

An electrocardiogram (Fig. 1) was taken onFebruary 11, 1957, with the following results: Sinusrhythm was normal. Auricular and ventricular rateswere 80 per minute. The P-R interval measured0.14 second. The QRS complexes demonstratedvertical electrical positions and were 0.08 secondwide. The S-T segments were slightly elevated inleads 2, 3, aVF, V 5, and V6. The T waves werecoved and inverted in leads 1, aVL, V„ V,, V„,V4 , and V5 . Successive electrocardiograms taken

every second day during the hospital stay showedan identical picture.

Laboratory data were as follows: hemoglobin,12.5 grams; hematocrit, 42 per cent; and leukocytes,8,000, with a differential count of 61 per cent seg-mented neutrophils, 37 per cent lymphocytes, 1 percent eosinophils, and 1 per cent monocytes. A uri-nalysis had normal results; purified protein deriva-tive test was negative; serology was nonreactive;and a blood culture was sterile. The sedimentationrate was 10 mm. at the end of 1 hour, which isconsidered normal at Metropolitan Hospital. TheC-reactive protein test was negative; antihyaluroni-dase titer was 64 units; antistreptolysin titer was 96units; the febrile agglutination series was negativein all dilutions; the viral series was negative; and theheterophil antibody titer was negative in a 1 to 8dilution. On repeated tests, results were approxi-mately the same.

During his hospitalization, the patient was keptat bed rest. For 10 days he was given penicillintablets, 400,000 units three times daily, 2 hoursafter meals, and 10 grains of aspirin every 4 hours.His temperature, which varied from 99 to 100.6 F,returned to normal after 5 days of hospital stay.

After 14 days, he was discharged with a diagnosisof pericarditis of unknown etiology, and he wasmanaged conservatively with bed rest at home for

JOURNAL A.O.A., VOL. 60. MARCH 1961 559

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1 month. At that time, he was asymptomatic. Hehad no joint pain, chest pain, or shortness of breath.His temperature was taken several times each dayby his parents, and it remained within normalrange. An electrocardiogram was taken on March20, and another on April 17, 1957. Both of theseshowed some persistent T-wave negativity in lead1 and also over the apex in the precordial leads.

The blood sedimentation rate done by the Cutlermethod demonstrated a level of 7 mm. at the endof 1 hour. Fluoroscopic examination of the chestrevealed a centrally placed heart of normal size andconfiguration. On barium swallow, there was noevidence of left atrial enlargement. The aortic archwas on the left side.

At that time, nothing further could be addedconcerning the etiology in this case. It has beenknown that inverted T waves may persist for thislength of time in patients who have experiencedepisodes of pericarditis and myocarditis of a non-specific, benign nature.

Since the patient's sedimentation rate was nor-mal, he was permitted to return to school. It wassuggested that this be his major activity for thetime being, and that he be restricted from strenuousand competitive activities. It was further suggestedthat a repeat electrocardiogram be taken in 3 to 6months, and thereafter until some change occurredtoward the normal. The parents were advised thatthis type of attack of myocardial involvement couldpossibly recur. At this time, a diagnosis of acutebenign pericarditis was made, since this diagnosisseemed compatible with the findings in this case.

On August 2, 1957, the patient was again exam-ined. Since approximately May 1, 1957, he had beenon almost full physical activity. He had suffered no

portant intercurrent intercurrent illnesses. He had no com-plaints except for some vague discomfort in thefeet when climbing steps. The electrocardiogramcontinued to show the same T-wave negativity inleads 1, V„ and V,. There was a slight and ques-tionable improvement in these T-wave abnormali-ties, as compared to the earlier tracings.

On November 26, 1957, the patient was againexamined. Physical examination showed him to bewell developed and well nourished, with no respira-tory distress or cyanosis. The blood pressure was120/80, and the pulse rate was 72 per minute. Nosignificant cardiac murmurs were audible. Thefemoral pulses were readily palpable. Fluoroscopicexamination of the chest revealed a heart of normalsize, shape, and position. An electrocardiogram hadbeen taken on November 23 (Fig. 2), and it con-tinued to show the flight flattening and inversionof the T waves in leads 1, V 5 , and V.

Except for the electrocardiographic abnormali-ties which we know to have been present sinceFebruary 1957, and perhaps for a longer period,there are now no cardiac abnormalities in this boy.These findings are now considered to have stabi-lized. For this reason, there was no need to restrictthe patient's physical activity, except perhaps forstrenuous competitive sports.

After 3 years of following the progress of thisboy, his electrocardiogram is still similar to thattaken on November 23, 1957. He is, however, com-pletely symptom-free and his physical examinationshows him to be healthy.

1. McGuire, J., Kotte, J. H., and Helm, R. A.: Acute pericarditis.Circulation 9:425-442, March 1954.

2. Friedman, S., et al.: Acute benign pericarditis in childhood:comparisons with rheumatic pericarditis, and therapeutic effects ofACTH and cortison. Pediatrics 9:551-563, May 1952.

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