Case presentation:
A previously healthy 50-years old Sudanese man with no prior significant medical history came to a university hospital, Sudan, complaining of chest pain, stabbing in nature, increased in severity when supine position and improved with leaning forward. He denied any history of cough or shortness of breath.
During the physical examination, the patient preferred sitting leaning forward, not dyspneic. Her BP was 160/80, pulse rate 96 regular, temperature 38.1 and oxygen saturation 96 % on room air. The JVP was not raised. Pericardial friction rub was not heard. Cardiovascular and chest examination was unremarkable.
Initial laboratory investigations revealed the following: WBCs 11.0 × 109/L (4.0 -11.0 × 109/L), lymphopenia 5%, ESR 50mm / hour, The liver and kidney function were within normal values. D-dimer 350 ng / ml. Serum quantitative troponin was 0.5 ng/ml (normal lab value 0-0.6 ng/ml). The ECG showed widespread ST-segment elevation.
The diagnosis was acute pericarditis as he fulfilled two items of ESC diagnostic criteria for pericarditis (pericardiac chest pain and new widespread ST-segment elevation) in addition to elevation in inflammatory markers. The patient received I.V fluids and Ibuprofen tabs. Due to the current COVID-19 pandemic and lymphopenia, a nasopharyngeal swab for SARS-CoV-2 was taken to be tested by reverse transcription-polymerase chain reaction(PCR) and the result came as positive. The patient was admitted to the isolation centre of COVID-19 and received paracetamol infusion, low molecular weight heparin (LMWH) 75 IU / kg, dexamethasone 6 mg QID, and vitamins supplement.
On the fifth day of admission, the patient developed mild shortness of breath and dry cough. On physical examination, he was dyspneic and tachypnoeic, further assessment revealed that the apex beat is difficult to locate with muffled first and second heart sound, there no added sounds or murmurs. The ECG showed low voltage in all leads. (Figure 1) The chest radiograph revealed an enlarged cardiac silhouette and with the absence of pulmonary infiltrates, and no pleural effusion was detected. (Figure 2). Subsequently, a transthoracic echocardiogram was performed which showed a moderate pericardial effusion with no regional wall motion abnormalities.(Figure 3) The LVEF was 55%. The patient was continued on LMWH 75 IU / kg, dexamethasone 6 mg QID, and vitamins supplement.