Acute Pericarditis Caused by Pulmonary Embolism: A Dressler-Like Syndrome

Pericarditis presenting as a sequelae of myocardial infarction, pericardiotomy or chest trauma is well recognized; but it is rarely described in association with pulmonary embolism. A 40 year old caucasian male with no significant past medical history presented with new-onset shortness of breath and substernal chest pain worsening over the preceding three days. He is a never smoker. One week prior he drove to Texas from Colorado. The main differential diagnosis based off the history was pulmonary embolism, acute coronary syndrome, pleurisy and musculoskeletal chest pain. Electrocardiogram showed sinus tachycardia with S1Q3T3. Chest CTA showed a saddle embolus and evidence of right ventricular strain. Transthoracic echocardiogram showed markedly dilated right ventricle with mild hypokinesis of the mid free wall and McConnell's sign. EKOS catheter was then placed for 12 hours. The patient improved and was discharged on an oral anticoagulant with scheduled outpatient follow-up. One week later he presented to our ER with chest pain radiating to the back. A friction rub was present on cardiac auscultation. EKG showed normal sinus rhythm with diffuse ST elevation, PR depression and Spodick's sign. Troponin levels were negative, TTE showed improved RV strain and preserved LV function. CRP and ESR were significantly elevated. He was diagnosed with pericarditis and started on indomethacin and colchicine. Pulmonary embolism can cause right heart strain via increased pulmonary vascular pressures. This strain can lead to transmural infarction in the right heart which can then lead to acute pericarditis.