MedPix Medical Image Database COW - Case of the Week Case Contributor: MS-4 USU Teaching File Affiliation: Uniformed Services University

MedPix No: History Pt Demographics: Age = 16 y.o. Gender = Male This is a 16 yo male originally presented to his PCP in April with c/o chest pain and low-grade fever that interfered with his normal daily activity. He was treated with NSAID and was immediately able to resume his regular schedule. On July 14th the patient had a 2nd episode of chest pain and low-grade fever. He was admitted to ????? where he underwent a pericardialcentesis and was treated with a brief course of IV steroids. Lab studies during his first admission were positive for RF and ANA and negative for M. pneumoniae, Lyme disease, coxsackie virus A or B, echovirus, heterophile antibodies, CMV and HIV. Bacterial, fungal and TB cultures were all negative and pericardial fluid showed 12,700 WBCs and 2000 RBCs. The pt was d/c pain free after a 3-day admission but presented again on 23 July for a 3rd episode of chest and low-grade fever. PMHx significant for episode of viral meningitis in PSHx significant for tonsillectomy/adenoidectomy and PET placement. FMHx is negative for both cardiac and rheumatologic disease. The pt is on no medications and denies illicit drug use. Downloaded by (-1)

MedPix No: EXAM & LABS

Chest PA (7/14/01): Findings: The cardiac silhouette appears slightly enlarged on the AP view but this finding is not evident on the lateral view. The lungs and pleural margins are clear. The cardiomediastinal contour is within normal limits. The pulmonary vasculature is unremarkable. - Impression: Cardiac size likely within normal limits given its normal appearance on lateral view. Lungs are clear. - Downloaded by (-1)

Chest Lateral (7/14/01): Findings: The cardiac silhouette appears slightly enlarged on the AP view but this finding is not evident on the lateral view. The lungs and pleural margins are clear. The cardiomediastinal contour is within normal limits. The pulmonary vasculature is unremarkable. - Impression: Cardiac size likely within normal limits given its normal appearance on lateral view. Lungs are clear. - Downloaded by (-1)

Chest PA (7/23/01) Findings: PA and lateral views of the chest demonstrate an enlarged cardiac silhouette with a globular shape with a cardiothoracic ratio of greater than 50%. Blunting of the left costophrenic angle is also evident. The azygous vein is distended above 1 cm. There is no evidence of pneumothorax or pneumoperitoneum. Bony structures are within normal limits. - Impression: Enlarged globular cardiac silhouette suggests pericardial effusion. Distension of the azygous vein suggests cardiac tamponade. Left pleural effusion is evident. - - Downloaded by (-1)

Chest Lateral (7/23/01) Findings: PA and lateral views of the chest demonstrate an enlarged cardiac silhouette with a globular shape with a cardiothoracic ratio of greater than 50%. Blunting of the left costophrenic angle is also evident. The azygous vein is distended above 1 cm. There is no evidence of pneumothorax or pneumoperitoneum. Bony structures are within normal limits. - Impression: Enlarged globular cardiac silhouette suggests pericardial effusion. Distension of the azygous vein suggests cardiac tamponade. Left pleural effusion is evident. - - Downloaded by (-1)

FINDINGS Chest PA and Lateral (7/14/01): Findings: The cardiac silhouette appears slightly enlarged on the AP view but this finding is not evident on the lateral view. The lungs and pleural margins are clear. The cardiomediastinal contour is within normal limits. The pulmonary vasculature is unremarkable.Impression: Cardiac size likely within normal limits given its normal appearance on lateral view. Lungs are clear.Chest PA and Lateral (7/23/01) compared to 14Jul01:Findings: PA and lateral views of the chest demonstrate an enlarged cardiac silhouette with a globular shape with a cardiothoracic ratio of greater than 50%. Blunting of the left costophrenic angle is also evident. The azygous vein is distended above 1 cm. There is no evidence of pneumothorax or pneumoperitoneum. Bony structures are within normal limits.Impression: Enlarged globular cardiac silhouette suggests pericardial effusion. Distension of the azygous vein suggests cardiac tamponade. Left pleural effusion is evident.

DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis?

Diagnosis: Pericarditis with pericardial effusion Dx Confirmed by:

DISCUSSION