Acute non-rheumatic myopericarditis: a rare complication of
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Acute non-rheumatic streptococcal myopericarditis (ANRSM) is a rare complication of an upper airway infection by streptococcus group A. The present case study, published in the European Journal of Internal Medicine Case Reports, describes recurrent ANRSM in an 18-year-old man, which illustrates how difficult and challenging the diagnosis of this disease can be.

An 18-year-old man with no previous medical history and not taking chronic medication was referred for suspected ST-elevation AMI. He had a stabbing chest pain lasting for 6 hours that did not improve with a single dose of ibuprofen 400 mg.

The ECG showed normal left ventricular function with no valvular disease or pericardial effusion, but due to the abrupt onset of symptoms and elevated troponin, the patient was submitted to urgent coronary angiography that revealed normal coronary arteries. The patient was put on 24-hour ECG recording that did not reveal any pathological dysrhythmias.

Therefore, the diagnosis of myopericarditis of viral aetiology was presumed on the basis of the history of an upper airway infection in the previous week. Treatment with acetylsalicylic acid 1 g three times a day and colchicine 0.5 mg two times a day was started. The patient was discharged on the third day after resolution of the chest pain.

One week before the scheduled consultation, the patient had another episode of sudden chest pain with the same characteristics. Simultaneously he had complaints of odynophagia and tonsillitis which was treated with azithromycin 500 mg a day Physical examination was unremarkable except for the oropharynx which revealed inflammatory signs with bilateral tonsillar oedema and a purulent plaque. The ECG at admission revealed ST elevation from V3 to V5 and T wave inversion on DI, aVL, V3 and V4.

The association between the two respiratory infections and both episodes of chest pain pointed towards a possible pathological connection. Therefore, a rheumatic factor rapid antigen swab test and an antistreptolysin O titre test were performed; the first was negative but the latter was positive with an antistreptolysin O of 2,110 IU/ml (normal range <200 IU/ml).

Antibiotic therapy was changed to amoxicillin 500 mg three times a day, and the diagnosis of ANRSM was made based on the clinical presentation. The patient was also referred for otolaryngologist evaluation for tonsillectomy due to the high risk of recurrence of myopericarditis associated with another upper airway infection.

• The diagnosis is made on the basis of a recent upper airway infection by streptococcus group A in the absence of a rheumatic setting.

• Cardiac imaging (mainly ultrasound and magnetic resonance) plays a major role in making the diagnosis.

• Prognosis is very good when appropriate treatment with antibiotics and non-steroidal inflammatory drugs is provided.

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