Case Report © 1991 S. Karger AG, Basel 0008-6312/91/0782-0156S2.75/0

Cardiology 1991;78:156-160

Acute Nonrheumatic Perimyocarditis Complicating Streptococcal Tonsillitis Chaim Putterman, Yoseph Caraco, MeirShalit Department of Internal Medicine A, Hadassah University Hospital, Kiryat Hadassah, Jerusalem, Israel

Key Words. Streptococcus ■Tonsillitis • Myocarditis • Pericarditis Abstract. Streptococcal infection is a rarely recognized cause of nonrheumatic perimyo­ carditis. We report a case of a young patient who developed acute perimyocarditis as man­ ifested by diffuse electrocardiogram changes, and markedly elevated cardiac enzymes, con­ currently with streptococcal tonsillitis. Despite the dramatic presentation, the patient recov­ ered uneventfully. We conclude that streptococci can involve the heart also directly by a bacterial component or toxin, and not only through a delayed immunologic mechanism as in rheumatic fever. Further studies are necessary to accurately determine the incidence of myocardial involvement during early stages of streptococcal infection.

The most common infectious agents clearly associated with myopericarditis are coxsackievirus B, infectious mononucleosis, vaccinia virus and Mycoplasma pneumoniae [1], Streptococci are usually involved in myocarditis only when associated with rheu­ matic fever. Recently, it has been recognized that streptococcal infection, particularly ton­ sillitis, can be associated with acute nonrheu­ matic perimyocarditis [2], In this study, we report an additional case of acute perimyo­ carditis, complicating febrile streptococcal tonsillitis.

Case Report A previously healthy white 20-year-old male pre­ sented to the emergency room with oppressing left­ sided chest pain, radiating to his left arm. The pain was dull and did not change with movement or respi­ ration. Two days before, medication with oral penicil­ lin for exudative tonsillitis was begun, after he com­ plained of fever and a sore throat. Physical examina­ tion on admission revealed a blood pressure of 110/60 mm Hg, a regular heart rate of 90 b.p.m. and an oral temperature of 38 °C. Inspection of the phar­ ynx showed exudative tonsillitis. Enlarged and tender submandibular lymph nodes were palpated. Exami­ nation of the heart was essentially normal, and no pericardial rub, murmurs or extra heart sounds were heard. The remainder of the physical examination was within normal limits. The chest roentgenogram

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Introduction

Nonrheumatic Streptococcal Perimyocarditis

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was unremarkable, with no cardiomegaly, lung infil­ trates or signs of cardiac failure. An electrocardio­ gram (ECG) showed a sinus rhythm at 90 b.p.m., with a 4-mm S-T segment elevation in leads 1, 2, aVL, aVF, and V4-V 6, and T wave inversion in leads V |-V 3 (fig. 1). The erythrocyte sedimentation rate was 65 mm in the 1st hour. The white blood cell count was 12,600 mm3, with the differential count showing 77% neutrophils, 17% lymphocytes and 6% monocytes. Creatine kinase level was 1,213 U/l and the MB fraction 43 U/l (normal < 1 0 0 and < 5 , respectively). Aspartate aminotransferase was 201 U/l (normal < 35) and the lactic dehydrogenase 520 U/l (normal

Acute nonrheumatic perimyocarditis complicating streptococcal tonsillitis.

Streptococcal infection is a rarely recognized cause of nonrheumatic perimyocarditis. We report a case of a young patient who developed acute perimyoc...
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