Here, we describe a 34 year-old female admitted with five days of worsening left sided pleuritic chest pain and shortness of breath. Her medical history is significant for four presentations to the emergency department and two admissions for similar symptoms over the last six months. The diagnosis of pericarditis was made on the most recent hospital admission one-month prior where pericardial window was also done.
At the time of admission, the patient was afebrile, normotensive and mildly tachycardic. Physical exam was noteworthy for no jugular venous distention and otherwise normal cardiopulmonary exam. Laboratory studies included WBC of 12.3, ESR of 66, CRP of 8.95, and negative troponin. Initial workup included normal CXR and EKG with diffuse T-wave inversions. Transthoracic echocardiogram showed small circumferential pericardial effusion without any evidence of cardiac tamponade. On the previous admission, pericardial fluid revealed WBC of 412 (71% neutrophils, 25% lymphocytes, 4% macrophages), glucose of 84, and LDH of 372. Other notable diagnostic studies include: normal complement levels, ANA titer of 1:40, negative double-stranded DNA, QuantiFERON-TB gold, HIV, RPR, Coccidioidomycosis, cyclic citrullinated peptide, rheumatoid factor, ANCA, Coxsackie A and B, Cytomegalovirus, Ebstein-Barr virus, and respiratory viral panel.
The patient was maintained on her home dose of Colchicine. Ibuprofen was switched to Indomethicin with improvement of her symptoms. CT chest, abdomen and pelvis with contrast was obtained revealing no signs of malignancy. She had a positive HSV 1 IgM titer. However, patient denied any prior HSV lesions in the mouth or genital area. Patient was discharged home on Colchicine and Indomethicin with plan to taper off Indomethicin and restart Ibuprofen.
Given that an extensive workup for the most recognized causes of acute pericarditis including malignancies, infections, and autoimmune diseases were negative the diagnosis of idiopathic recurrent acute pericarditis is possible. Similar negative workup occurs in approximately 80% of all cases. Genetic tests for the most well described periodic fever syndromes including familial Mediterranean fever and Tumor Necrosis Factor Receptor-Associated Periodic Syndrome will be considered as an outpatient. On the differential diagnosis is also HSV pericarditis. While there have been reports of HSV pericarditis in immunodeficient individuals, this has never been reported in an immunocompetent host. If the patient were to have significant pericardial fluid again, HSV PCR and serologies from pericardial fluid will be sent to confirm the diagnosis.
The underlying etiology of idiopathic recurrent acute pericarditis remains controversial, as it may be a cross of infectious, autoimmune, or autoinflammatory etiologies. Viral etiologies are the presumed culprit in the majority of cases however often a specific virus is not identified. HSV should be recognized as a possible etiology of acute pericarditis and if confirmed may offer different treatment modalities.