Regional pericardits: a mischievous masquerader.

Dear Editor,

We read with great interest the work by Orme et al. published in recent issue of the North American Journal of Medicine and Science.[1] They highlight an interesting concept of electro cardiogram (ECG) manifestation in regional pericarditis.

Indeed, regional pericarditis is a valid consideration given a recent history of ablation procedure. However, a few alternate diagnostic considerations would be of value such as transient coronary vasospasm especially given the reciprocal ST-depressions in the inferior leads. Serial ECG monitoring and information on temporal resolution (not provided in the case illustration) would be of great value for the diagnostic confirmation. Temporal ECG changes often add a diagnostic value especially in challenging cases (temporal T-wave inversions simultaneous to the ST-elevations often support myocardial ischemia as opposed to pericarditis). Atypical progression of T wave viz. persistently positive T-waves for 48 h after symptom onset, and premature and gradual reversal of inverted T-waves to persistently upright T-waves, is 100% sensitive and 77% specific for regional pericarditis.[23]

Again, if the vasospasm is excluded as a diagnostic consideration, the ST-depressions in the inferior leads and positive troponin strongly suggest a trans-mural inflammatory process suggestive of regional peri-myocarditis as opposed to pericarditis alone.[4]

Though regional pericarditis is certainly a challenging diagnosis, we want to emphasize that the presence of pericardial rub is a diagnostic hallmark for regional epistenocardiac pericarditis.[5] For the obvious value of correct clinical diagnosis, a careful serial examination in these cases is often helpful since pericardial rub may often be transient.[6] Nonetheless, the cardiac magnetic resonance imaging (MRI) would have been the gold standard confirmatory modality in the presented case.[7]