Case Presentation: A 21-year-old male with no past medical history presented to the emergency room with sudden onset chest pain, bradycardia, and hypotension. He described feeling chest “pressure” that led to shallow breaths. His pain was substernal, pleuritic, non-radiating, and associated with palpitations. He had mild relief when sitting up. Symptoms started that morning and worsened an hour prior to presentation. He was otherwise in his usual state of health, save for an upper respiratory illness two weeks prior. On arrival to the emergency room (ER), he was bradycardic (50 bpm) and hypotensive (90/30 mmHg). Physical exam demonstrated diaphoresis, shallow breathing, and a slow regular heart rate and rhythm. Initial EKG showed sinus bradycardia without PR or ST segment changes. His WBC was 14 x 103/mcL, while BMP, ESR, CRP, LDH, pro-BNP, and high-sensitivity troponin were all within normal limits. Emergent CT angiography of the chest, abdomen, and pelvis was unrevealing for any acute pathologies. While in the ER, his blood pressure dropped further, so he was started on norepinephrine and sent to the cardiac intensive care unit. Blood cultures and urine analysis were negative. Transthoracic echocardiogram showed a left ventricular ejection fraction of 57% with normal function and no pericardial effusion. As his heart rate and blood pressure normalized, he was weaned off of norepinephrine and treated empirically for possible gastroesophageal reflux disease and pericarditis with famotidine and ibuprofen. He was transferred to the general medicine service within 24 hours of presentation. There, he continued to report chest pain. Repeat EKG showed diffuse ST segment elevation. Repeat ESR was elevated at 28 mm/Hr, and CRP was 147 mg/L. Cardiology was consulted and confirmed a diagnosis of acute viral pericarditis. He was discharged on a three-month course of colchicine and a three-week taper of ibuprofen.

Discussion: Acute pericarditis, a condition characterized by inflammation of the pericardial sac, is often caused by viral illness. (1) Classically, acute pericarditis presents with retrosternal, pleuritic chest pain that improves with leaning forward (1) and is often associated with sinus tachycardia. (2) In the absence of a pericardial effusion causing restrictive physiology, bradycardia and hypotension is uncommon. (2) To our knowledge, only two cases of acute pericarditis have reported bradycardia, likely a vasovagal response to chest pain, as the presenting symptom. (2,3) EKG findings and inflammatory marker elevation can help guide diagnosis; however, they have temporal variability and may not show in the acute phase of pericarditis. PR segment depression usually presents 12 hours after pain onset, while ST segment elevations present 36 hours after. (4) CRP plasma concentrations rise >5 mg/L in 6 hours and peak at 48 hours. (5) These EKG findings have a sensitivity of 60% and CRP elevation occurs only in 75% of cases. (5,6)

Conclusions: In a young person presenting with retrosternal chest pain, acute pericarditis is an important diagnosis to consider, even with atypical presentation of symptomatic bradycardia and hypotension in the absence of pericardial effusion. EKG findings and inflammatory marker elevation can help guide diagnosis but have a temporal effect. Clinicians should consider serial readings if they were normal initially. Confirmation of diagnosis is essential to solidify treatment plans as treatment courses are long.