"Julio," a 14-year old boy, presented to the emergency department (ED) with his parents for treatment of an acute illness. Julio had not been feeling well the previous day. He reported "food poisoning" with one emesis and went to bed with "flu-like" symptoms. He awoke with pain in his chest that persisted throughout the school day, with worsening in the 2 hours preceding ED presentation. An intravenous line was started and labs were drawn. He was not placed on supplemental oxygen.

In the ED, Julio reports no pain or dizziness. Julio is not a student athlete. He says he does not use drugs, alcohol or tobacco. He says he has taken aspirin and ibuprofen in the past 24 hours. Julio is described by his parents as a good student and a good kid. He appears to have a good relationship with his parents, interacting and conversing with them in normal tones and making regular eye contact. There is no family history of premature heart disease (including sudden death), diabetes or hypertension.

Julio is a well developed young man who is more than 6 feet tall and weighs 203 pounds. He is in no apparent distress. He has noticeably long fingers and large feet, with a mesomorphic body habitus. His gait is normal. Julio's lungs are clear and he has a normal cardiac exam without murmur, gallop or thrill. There is no pectus deformity, obvious scoliosis or joint laxity. He has no pedal edema and his skin turgor is adequate. Julio does not wear corrective eyeglasses. Pupils are equal and reactive; there is no papillary edema. I order an electrocardiogram (ECG). Vital signs show his blood pressure as 111/67 mm Hg, pulse 82, respiratory rate 18, temperature 98.5 degrees Fahrenheit, and pulse oximetry 98% on room air. His chest radiographs are normal. I order a second verifying ECG (see figure) and right-sided ECG.

Differential Diagnoses

The suggestion of acute posterior myocardial infarction was based primarily on history of present illness, initial ECG and laboratory indices (Table 1). The initial ECG was significant for supraventricular (ST) elevation in the inferolateral leads with mirrored changes (ST depression and T-wave inversion) in leads V₁ and V₂.

The differential diagnoses included acute myocardial infarction (AMI), myocarditis or pericarditis. We consulted with cardiology services. The cardiologist evaluated the patient in the ED and followed Julio through his hospital course in consultation with a medical team.

Julio was taken emergently to the cardiac catheterization laboratory where left ventriculography, coronary angiography and right femoral angiography were performed. Ejection fraction was estimated to be 60% without hemodynamically significant coronary obstructive lesion and with normal left ventricular systolic function. Julio was admitted to the cardiac care unit to monitor his cardiac enzymes and initiation of medical management.

Angiotensin-converting enzyme inhibitors (lisinopril [Prinivil] 2.5 mg/day) and beta-blocker agents (atenolol [Tenormin] 12.5 mg twice a day) were promptly initiated that same evening. Subsequent cardiac isozymes for the entire hospitalization are illustrated in Table 2. The following morning, two-dimensional echocardiography was performed; the results were normal. Thyroid-stimulating hormone, amylase and lipase, and cholesterol panel l values were all within normal limits.

Julio had no further chest pain. He was discharged on day 3 with prescriptions for aspirin 325 mg daily, lisinopril 2.5 mg daily and atenolol 12.5 mg daily. The cardiologist planned for Julio to be medicated for at least 6 to 12 months, followed by cardiology and to undergo a repeat echocardiogram in 2 to 4 weeks. The cardiology dismissal summary reported that it was "difficult to determine whether the patient may have had a coronary spasm as a cause for his chest pain and elevation in cardiac enzymes versus significant pericarditis/myocarditis. Given the patient's good health and young age, however, it has been determined that the most likely cause of his chest pain was viral in etiology causing pericarditis/myocarditis."