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5 Two weeks after hospital discharge for documented myocardial infarction, a 65-year-old returns to your office very concerned about low-grade fever and pleuritic chest pain. There is no associated shortness of breath. Lungs are clear to auscultation and heart exam is free of significant murmurs, gallops, or rubs. ECG is unchanged from the last one in the hospital. The most effective therapy is likely
A) Antibiotics
B) Anticoagulation with warfarin (Coumadin)
C) An anti-inflammatory agent
D) An increase in antianginal medication
E) An antianxiety agent
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The answer is c. The history and physical are consistent with post-cardiac injury syndrome (in the past also known as Dressler syndrome or postmyocardial infarction syndrome). This generally benign self-limited syndrome comprises an autoimmune pleuritis, pneumonitis, or pericarditis characterized by fever and pleuritic chest pain, with onset days to 6 weeks post cardiac injury with blood in the pericardial cavity, as after a cardiac operation, cardiac trauma, or MI. Therefore the most effective therapy is a nonsteroidal anti-inflammatory drug or occasionally a glucocorticoid. Infection such as bacterial pneumonia, which would require antibiotics, would typically cause dyspnea, cough with sputum production, and rales on lung auscultation. Pulmonary embolus, which would require anticoagulation, would cause dyspnea and tachypnea, often in conjunction with physical findings of heat, swelling, and pain in the leg consistent with deep vein thrombosis. Angina or recurrent myocardial infarction is always a concern post MI (and what the patient usually fears in this situation), but the nature of the pain-here pleuritic rather than pressurelike-and the unchanged ECG are fairly reassuring and mitigate against an increase in antianginal therapy. Anxiety can be present but would not cause fever.
