When Pericarditis Is Not Pericarditis: Challenging Diagnostic Labels In A Football Player With Chest Pain

HISTORY: A 25 year old male second tier Australian Rules football player presented for return to play assessment following a diagnosis of viral pericarditis. Chest pain began 2 months earlier, with intermittent pain, shortness of breath, and fatigue appearing after a viral infection. Pain was localised to the left of the sternum and along the left ribs at rest and with exertion. Pericarditis was suspected due to ECG findings of high take-off at the ST-T junction and a trivial pericardial effusion on echocardiography. Inflammatory markers were normal, and no pericardial rub was heard at time of diagnosis. PHYSICAL EXAMINATION: Heart rate 60 bpm; blood pressure 115/70 mmHg; pectus excavatum with mild pain on palpation immediately to the left of the sternum. Heart sounds were dual with no added sounds. DIFFERENTIAL DIAGNOSIS: Costochondritis or Tietze syndrome. TEST AND RESULTS: Echocardiogram Normal LV size and systolic function; LVEF 59%; trivial pericardial effusion. CPET RER and RPE consistent with maximal effort. ECG normal at rest and during exercise. VO 2 peak 44.8 ml/kg/min (102% predicted, lower than expected for a semi-professional athlete). Ventilatory threshold 59% of predicted VO 2 peak. FINAL WORKING DIAGNOSIS: In the absence of classic ECG changes or clinical signs of pericarditis, the working diagnosis was costochondritis with increased fatigue and deconditioning due to decreased cardiorespiratory fitness in the setting of advised physical activity restriction. TREATMENT AND OUTCOMES: NSAIDs and local cortisone injection were administered by the sports physician, resulting in marked improvement in symptoms. Exercise physiologist prescribed exercise for a gradual return to training volume, using CPET heart rate data to determine training zones. Aerobic exercise commenced with run/walk intervals of 5 × 6 min/1 min at Zone 2-3 intensity (RPE 5-6/10), progressing approximately 10% weekly, with tempo/subthreshold work added and progression to continuous running. Stretching for the chest and upper back and modifications to resistance training were included. Resolution of chest pain and fatigue with repeat CPET after one month of structured exercise. VO 2 peak 51 ml/kg/min (109% of predicted), an increase of 6.2 ml/kg/min (14%). The athlete returned to game-specific training and competitive play.