A PERICARDIAL PUZZLE: A CASE OF IDIOPATHIC RECURRENT ACUTE PERICARDITIS

Document Type

Conference Proceeding

Publication Date

7-17-2025

Publication Title

J Gen Intern Med

Keywords

anakinra, antinuclear antibody, autoantibody, C reactive protein, colchicine, ibuprofen, interleukin 1, lactate dehydrogenase, lupus anticoagulant, prednisone, rheumatoid factor, adult, anxiety, asthma, case report, clinical article, conference abstract, diagnosis, drug therapy, dyspnea, echocardiograph, echocardiography, electrocardiogram, electrocardiography, erythrocyte sedimentation rate, female, gastroesophageal reflux, human, intravenous drug administration, leukocytosis, pericardial effusion, pericardiocentesis, pericarditis, pericardium, pH, pleurisy, point of care ultrasound, puerperium, recurrence risk, serology, ST segment elevation, tachycardia, thorax pain, vaginal delivery

Abstract

CASE: A 29-year-old female with asthma and chronic, intermittent pleuritic chest pain presented with two days of positional chest pain five weeks postpartum after an uncomplicated, full-term spontaneous vaginal delivery. Her chest pain had previously been diagnosed as both acid reflux and anxiety. On initial presentation, she was afebrile and tachycardic at a rate of 130 beats per minute. Laboratory results showed leukocytosis (12.4 K/ uL), along with elevated C-reactive protein (20 mg/dL) and erythrocyte sedimentation rate (128 mm/Hr). Electrocardiogram showed diffuse ST elevations. Point of care ultrasound revealed a small pericardial effusion. CT showed mild pericarditis. Persistent tachycardia prompted a formal echocardiogram, notable for a moderate-sized pericardial effusion with concern for tamponade, requiring pericardiocentesis with drainage of 200cc of serosanguinous fluid resulting in clinical improvement. Fluid analysis showed elevated LDH (1447 IU/L), low pH (7.27), and neutrophilic leukocytosis. Blood and pericardial fluid cultures were negative. She was discharged on colchicine and ibuprofen. One week later, she returned with recurrent symptoms and persistence of pericardial effusion on repeat CT imaging. Laboratory workup was notable for continued leukocytosis (17 K/uL), positive antiphospholipid and lupus anticoagulant antibodies. Serologies for anti-nuclear antibody, anti-double stranded DNA, rheumatoid factor, antineutrophil cytoplasmic autoantibody were negative. She was initiated on a prolonged prednisone taper, and she was later initiated on an Interleukin-1 (IL-1) inhibitor (anakinra) in the outpatient setting due to suspected autoimmune etiology. She had notable improvement in inflammatory markers and her disease activity has remained stable over time. IMPACT/DISCUSSION: Idiopathic recurrent acute pericarditis (IRAP) involves a complex interplay of infectious, autoimmune, and autoinflammatory mechanisms. Although pericarditis can have various triggers, in approximately 85% of cases, no specific cause is identified, and the condition is labeled “idiopathic,” with reported recurrence rates of 20-50%. Persistent symptoms and refractory pericarditis despite standard treatment prompted an autoimmune evaluation, emphasizing the potential role of immunological and hormonal changes unique to the postpartum period. This case adds to the literature supporting the use of anakinra in refractory cases and highlights the importance of advanced diagnostics, autoimmune evaluation, and multidisciplinary care in managing IRAP. CONCLUSION: Recognize pericarditis as a potential cause of chest pain and dyspnea, even in young otherwise healthy individuals. Consider IL-1 receptor inhibitors for treatment of pericarditis unresponsive to standard therapies.

Volume

40

First Page

S133

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