N Engl J Med 373:263 - 271 | July 16 , 2015
Presentation of CaseDr. Diane Tseng (Medicine): A 20-year-old man was admitted to this hospital because of fever and a pericardial effusion.
The patient had been well until 5 weeks before this admission, when sore throat, subjective fever, malaise, and diffuse myalgias developed. On evaluation by his primary care physician on the second day of illness, a clinical diagnosis of streptococcal pharyngitis was made, and a 7-day course of oral penicillin was prescribed.
Three days later, the patient was seen in an urgent care clinic because of fatigue and worsening myalgias. He reported that the sore throat and fever had improved. A rapid antigen test for group A streptococcus was negative, and the patient returned home.
Fifteen days later, the patient returned to the urgent care clinic with persistent myalgias and malaise and a 5-day history of increased sore throat and fever. A throat culture for group A beta-hemolytic streptococcus was positive, and a blood culture was negative. Oral levofloxacin was prescribed, and the patient returned home.
Four days later, shortness of breath and pain on the left side of the chest developed. The patient returned to his primary care physician. The chest pain, which he rated at 6 on a scale of 0 to 10 (with 10 indicating the most severe pain), increased with deep inspiration and radiated to the left shoulder and back. The sore throat had improved, but fever, myalgias, and malaise persisted. The patient appeared ill. The white-cell count was 23,800 per cubic millimeter (reference range, 4700 to 10,800), the C-reactive protein level was 29.5 mg per deciliter (reference value, <0.8), the erythrocyte sedimentation rate was 96 mm per hour (reference value, <15), and a blood culture was obtained.
The next day, the patient was admitted to a hospital near his home. The temperature was 39.4°C, and tachycardia was present. Tests for influenza virus and respiratory syncytial virus were negative. A computed tomographic (CT) scan of the neck and a transthoracic echocardiogram were reportedly normal. Oral azithromycin and intravenous vancomycin, ceftriaxone, and hydromorphone hydrochloride were administered.
The patient’s pain improved somewhat, but fever and shortness of breath persisted. On the third hospital day, CT of the chest reportedly revealed right hilar and mediastinal adenopathy, small bilateral pleural effusions, bibasilar atelectasis, and no evidence of acute pulmonary embolism. A test for human immunodeficiency virus was negative. Antibodies indicative of past infection with Epstein–Barr virus were detected. Over the next 2 days, abdominal pain developed. On the fifth hospital day, CT of the abdomen and pelvis was performed; no abnormalities were noted in the abdomen or pelvis, but moderate bilateral pleural effusions, dependent bibasilar opacities, and a moderate pericardial effusion were seen in the visualized portion of the lower thorax. A transesophageal echocardiogram that was obtained the next day showed a small circumferential pericardial effusion with some fibrinous strands; no vegetations were seen, and the estimated ejection fraction was 65%. A tuberculin skin test was negative. Indomethacin and colchicine were administered orally.
Swelling of the shoulders and elbows, stiffness of the shoulders, and a faint erythematous rash on the face, neck, and arms developed. Fever (with temperatures between 38.9°C and 39.4°C) and myalgias persisted, and dyspnea progressively increased. The administration of intravenous fluids and supplemental oxygen (through a nasal cannula at a rate of 2 liters per minute) was begun. An antistreptolysin O titer was 289 IU per milliliter (reference value, <530). On the 11th hospital day, a repeat transthoracic echocardiogram showed a large anterior pericardial effusion and a moderate posterior pericardial effusion, as well as marked respiratory variation of tricuspid inflow. The patient was transferred to the cardiac intensive care unit at this hospital.
On admission to this hospital, the patient reported pain on the left side of the chest and in the left shoulder, dyspnea, diffuse myalgias, anorexia, and loose stools. His parents also reported that he had had jerking movements during sleep over the past 2 days. The patient was a college student and lived with roommates. He was sexually active and consistently used condoms. He had had no exposure to animals and had not traveled outside New England during the previous 4 years. He did not use tobacco, but he smoked marijuana approximately two times per month and drank five or six beers once per week. He had no known allergies. His brother had recently died at 32 years of age from intravenous-drug use that was complicated by fungal endocarditis with an abscess of the mitral-valve ring.
On examination, the patient appeared pale and fatigued. The temperature was 37.7°C, the pulse 102 beats per minute, the blood pressure 162/83 mm Hg, the respiratory rate 30 breaths per minute, and the oxygen saturation 94% while he was receiving supplemental oxygen through a nasal cannula at a rate of 2 liters per minute. Pulsus paradoxus measured 14 mm Hg. The heart sounds were distant. The jugular venous pressure was greater than 19 cm of water, and Kussmaul’s sign (distention of the jugular veins during inspiration) was present. There was dullness on percussion at both lung bases, and Ewart’s sign (dullness inferior to the left scapula, with bronchial breath sounds and bronchophony) was present. There was pitting edema of the legs below the knees and mild swelling around the shoulders and elbows, without effusions. There were faint pink macules on the forearms and the right antecubital fossa (Figure 1) that were no longer visible after 1 hour. The remainder of the examination was normal. Results of renal-function tests were normal, as were blood levels of magnesium, phosphorus, glucose, globulin, alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, amylase, and lipase. Other laboratory test results are shown in Table 1. The results of urinalysis were normal. A blood culture, chest radiograph, electrocardiogram, and echocardiogram were obtained.
Figure 1
A faint pink macular rash developed on the patient’s forearms that was no longer visible 1 hour later. (Photograph courtesy of Dr. Jeffrey Gelfand.)
Clinical Photograph.
Table 1 Laboratory Data.
Dr. Jonathan A. Scheske: An anteroposterior chest radiograph (Figure 2A), obtained with the patient in an upright position, showed that the cardiac silhouette was symmetrically enlarged and had an appearance that was consistent with the water-bottle sign (in which the rounded and enlarged cardiac silhouette on frontal chest radiography mimics the appearance of an old-fashioned water bottle); this finding is classically associated with pericardial effusion. There were no signs of specific cardiac-chamber enlargement, although cardiac dilatation could also cause the symmetrically enlarged cardiac silhouette. The presence of cephalization of the pulmonary vasculature, indistinct vascular markings, and peribronchial cuffing was consistent with interstitial pulmonary edema. There was blunting of the costophrenic angles and opacification of the lower lung zones bilaterally; these findings are consistent with bilateral small pleural effusions (larger on the left side than on the right) and associated atelectasis.
Figure 2 Imaging and Cardiology Studies of the Chest.
An anteroposterior chest radiograph (Panel A), obtained with the patient in an upright position, shows that the cardiac silhouette is symmetrically enlarged; this finding is consistent with the water-bottle sign, which is classically associated with pericardial effusion. The presence of cephalization of pulmonary vasculature, indistinct vascular markings, and peribronchial cuffing is consistent with interstitial pulmonary edema. There is blunting of the costophrenic angles and opacification of the lower lung zones bilaterally; these findings are consistent with bilateral small pleural effusions (larger on the left side than on the right) and associated atelectasis. An electrocardiogram (Panel B) shows PR-segment elevation in lead aVR, subtle PR-segment depression in leads I and II, and T-wave inversions in the mid-precordium. A transthoracic echocardiogram (Panel C) shows a moderate circumferential pericardial effusion (asterisks), with right atrial inversion during early atrial diastole (arrow). LA denotes left atrium, LV left ventricle, RA right atrium, and RV right ventricle.
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