Infectious Disease Case

Our talk this evening was on an infectious disease (ID) case by Sarah Housman, Primary Care Resident at BIDMC.

Case:
A 21M patient who is otherwise healthy complains of a sore throat, fevers, and chest pain. He had a fever 3 days prior. A nurse told him he had strep throat and started him on penicillin. The patient says it feels like someone is sitting on his chest.

In clinic:

• Has strep throat, no remarkable physical exam
• WBC 12
• 70% Neutrophils
• Trop 0.32
• CRP 91
• EKG: ST elevation everywhere
• Day 2 Labs showed Trop 1.09
• Echocardigram shows focal myocarditis and myoregional systolic dysfunction.

Differential Diagnosis:

• Myocarditis (inflammation of muscle tissue, enzyme count increases)
• Pericarditis (inflammation of lining of heart, ST and PR elevation on EKG)
• Myopericardits (heart tissue inflammtion and damage --> CRP elevation)

Diagnosis:
The patient has myopericarditis. Diagnose for both pericarditis and myocarditis conditions by EKG changes, auscultation, pleuric chest pain, cardiac enzymes elevated, depressed injection fraction certain areas are hypokinetic, and look at the MRI.

Treatment:

• NSAIDs (for 2 weeks)
• Cholchicine to prevent recurrence by inhibiting microtubule formation (for 3 months).
• The most common side effect is diarrhea.
• Patients who are at risk of peptic ulcer disease, kidney disease don’t tolerate NSAIDs.

What about the Strep Throat?

• Group A strep can cause myocarditis.
• This patient could have rheumatic fever.
• Use JONES Criteria to help diagnose.

JONES Criteria:

• J- joint pain and migratory polyarthritis
• O- (represents a heart) carditis
• N- painless nodules on achilles tendon
• E- erythema
• S- Sydenham's chorea

For diagnosis: one major criterion (chorea, carditis, migratory arthritis) PLUS two minor criteria (fever, arthralgias, elevated ESR and CRP, prolonged PR). Our patient has 1 major and 2 minor criteria.

Why not Rheumatic Fever?

• 2-4 weeks after developing strep throat, rheumatic fever develops.
• This patient's timing is 2 days, making rheumatic fever an unlikely case.

Conclusion:

• Because he met the criteria, the patient should go to the ID clinic and be treated for rheumatic fever. 
• Patient is on long term penicillin (5 yrs while he’s in college since he’s at the risk of getting strep again). 
• Also treated for myopericarditis with NSAIDs for 2 weeks and Colchicine for 3 months.