Acute pericarditis

Vignette says 30 year old male presents to the emergency department with central chest pain, which is aggravated by cough, inspiration and relieved by leaning forward, since the past few days; He also had fever, myalgia, sore throat for which he took analgesics from local pharmacy 2 weeks back and was gradually resolved; On auscultation pericardial friction rub is heard over the left parasternal region; Laboratory studies show increased CRP and ESR with normal cardiac troponins; ECG shows diffuse ST elevation and PR depression; Diagnosis? 

Diagnosis is acute viral pericarditis. 

Etiologies:-
1. Viral/idiopathic (80-90%): Coxsackievirus, influenza
2. Autoimmune: SLE, RA, post-MI (Dressler's syndrome)
3. Bacterial: TB (fibrinous), purulent (staph/strep)
4. Malignancy:-Lung/breast cancer metastases

Clinical Features:-
1. Severe retrosternal chest pain, pleuritic (aggravated by inspiration and cough), positional (worse when supine & relieved by sitting or leaning forward) that radiates to back, left ridge of trapezius, and neck. 
2. Pericardial friction rub (produced by the movement of the inflamed pericardial layers against one another).
3. Dyspnea.
4. Mild grade fever and myalgias (if viral etiology).

Diagnosis:-
1. ECG shows diffuse ST elevation and PR depression. 
2. Echocardiogram is used to assess for complications of acute pericarditis (effusion or tamponade); Isolated pericarditis shows normal in echocardiography. 
3. CT/MRI.
4. Inflammatory biomarkers (e.g. CRP, ESR) are elevated and Cardiac Biomarkers (usually negative, positive indicates concurrent myocarditis).

Management:-
1. First-line Therapy: NSAIDs (e.g. ibuprofen) + Colchicine along with PPI's cover. 
2. Refractory Cases: Corticosteroids (prednisone 0.5 mg/kg/day, taper over 4 weeks): Reserve for autoimmune pericarditis. Avoid in viral cases (↑ recurrence risk).