Undiagnosed Chilaiditi syndrome presenting with pericarditis in a patient with congenital anomalies

Abstract

DesCripTionA 19-year-old male patient presented to the emergency room with dyspnoea and severe retrosternal chest pain. The patient's medical history is significant for cerebral palsy with spastic tetraplegia. He layed in a semirecumbent position as pain was severe on lying down. The pain radiated to the back, neck and shoulder. Pain was associated with gastro-oesophageal reflux disease and dysuria. On examination, he was breathless, and lungs were clear to auscultation. On auscultating over the heart, pericardial rub was heard. Abdomen was tender on palpation and he did not defecate for 2 days. He had a history of recurrent pneumonia that needed frequent hospital admissions and currently receiving treatment as the last episode was 1 month ago.ECG showed widespread concave ST elevation and PR depression with reverse changes in aVR of ST depression and PR elevation with sinus tachycardia suggesting early stage of pericarditis. Sputum culture was negative. Chest X-ray was done (figure 1) and revealed an area of previous pneumonia in the right lung and enlarged left border of heart, which was not definitive of pericarditis because of the rotational effect of his scoliosis, but raised the need for further investigation into the presumptive diagnosis of pericarditis. C reactive protein was elevated on laboratory investigation. Transthoracic echo was not significant besides that all other findings met the criteria for the diagnosis of pericarditis, that is, at least two from (1) characteristic chest pain, (2) pericardial rub, (3) ECG changes (widespread ST elevation and/or PR depression) and (4) new pericardial effusion. While examining the X-ray further, the most remarkable finding was the presence of large intestine loops between the liver and diaphragm, which was previously undiagnosed.