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A 28-year-old man with chest and joint pains
  1. Andrew W Ertel1,
  2. Simone Romano2,3,
  3. Afshin Farzaneh-Far2,4
  1. 1Medstar Heart and Vascular Institute, Medstar Georgetown University Hospital, Washington DC, USA
  2. 2Section of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
  3. 3Department of Medicine, University of Verona, Verona, Italy
  4. 4Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
  1. Correspondence to Dr Afshin Farzaneh-Far, Section of Cardiology, University of Illinois at Chicago, 840 South Wood St M/C 715, Suite 920 S, Chicago, IL 60612, USA; afshin{at}


Clinical introduction A 28-year-old man with extensive travel history to developing countries was hospitalised for intermittent sharp chest pains, worst when supine and with inspiration. Two weeks prior to presentation, he had suffered a flu-like illness with a sore throat, which was resolving. Physical examination was notable for mild fever and tachycardia with cervical lymphadenopathy and painful bilateral knee and wrist effusions. Cardiac auscultation was remarkable for a soft early-peaking systolic murmur over the aortic area with a decrescendo early diastolic murmur along the left sternal edge. There was mild leucocytosis, elevation of serum troponin and acute-phase reactants with an ECG showing sinus tachycardia. Echocardiographic windows were extremely limited but suggested the presence of pericardial effusion and aortic regurgitation. Cardiac MRI was performed (figure 1). Viral, microbiological and autoimmune testing was remarkable only for significant elevation of antistreptolysin-O titres (1450 IU rising to 1940 IU, normal <200 IU). Pericardiocentesis revealed an exudative effusion, which was negative by cytology and microbiological analysis, including for tuberculosis and fungi.

Question The most appropriate next step is?

  1. Coronary angiography

  2. Endomyocardial biopsy

  3. Treatment with colchicine for 3 months

  4. Treatment with corticosteroids

  5. Treatment with high-dose salicylates and long-term penicillin

For the answer see page 808

For the question see page 769

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