Chest pain in a young woman- should be an easy one

It looked like an easy one for a change. I picked up the chart of my new patient- a 36 year old woman complaining of chest pain. She appeared to be a fit healthy woman in no obvious stress. Immediately, I began considering the differential diagnosis of chest pain in a young woman. The usual suspects quickly came to mind: chest wall strain, costochondritis- inflammation of the cartilage where the ribs join the sternum, a trapped gas bubble, stress/anxiety, lung infection- especially pleurisy, possible mitral valve prolapse, acid reflux disease and a few others. Coronary heart disease seemed quite unlikely. Pericarditis was near the bottom of my list.

I then took the patient's history. The pain had been present for two months, but recently- over the past one week, it had become more severe. It was constant and was located in the left chest area. It was not pleuritic (it did not increase with respiration). It did not radiate. It was not associated with sweating or shortness of breath. She did not have heartburn. The pain was not reproducible with pressure applied to the chest wall or with movements of her body. There was no history of trauma. These are standard doctor questions in the evaluation of chest pain.

What made the pain better or worse? The pain improved with aspirin and with leaning over. Interesting.

Oddly enough she complained of severe fatigue. She denied a history of a recent respiratory infection or viral syndrome.

And then oddly enough she complained of occasional night sweats over a period of two months corresponding to the time frame of the chest pain. I filed this away in my head.

Her history and exam were unremarkable. She had a mild systolic heart murmur but I thought it was within the normal range.

To be complete I performed an EKG: normal. I considered the fact that the pain decreased when she bent over. I recalled that pericarditis associated chest pain can improve with a change in position. Frequently bending forward makes it worse rather than better.

I have on site cardiac echo. To be thorough, I performed an echocardiogram.

The findings were surprising. There was fluid around the heart in the pericardial sack. This is compatible with the diagnosis of pericarditis. Frequently preicarditis in an otherwise healthy young woman is due to a viral infection and is self limiting. Of course there is a long list of disorders which may cause pericarditis, including: lupus and other autoimmune syndromes, tuberculosis, HIV, fungal infections, parasitic infections, bacterial infections, kidney disease, and unusual cardiac disorders. I also know that pericarditis can be a manifestation of Lyme disease. I ordered an anti inflammatory drug, Indocin assuming she had viral pericarditis.

As we were finishing up the visit I asked another question, as an after thought: Have you had any tick bites?

She answered: Yes, three years ago, it was a tiny tick and I could barely see it. I think there was a rash as well.

Pericarditis, fatigue, night sweats and a tick bite: I had to connect the dots- It looks like Lyme yet again.