Huang et al. BMC Cardiovasc Disord (2021) 21:394 https://doi.org/10.1186/s12872-021-02200-5 CASE REPORT Open Access Post cardiac injury syndrome successfully treated with medications: a report of two cases Mu‑Shiang Huang1†, Yan‑Hua Su2† and Ju‑Yi Chen1* Abstract Background: Post cardiac injury syndrome (PCIS) is induced by myocardial infarction or cardiac surgery, as well as minor insults to the heart such as percutaneous coronary intervention (PCI), or insertion of a pacing lead. PCIS is char‑ acterized by pericarditis after injury to the heart. The relatively low incidence makes diferential diagnosis of PCIS after PCI or implantation of a pacemaker a challenge. This report describes two typical cases of PCIS. Case presentation: The frst patient presented with signs of progressive cardiac tamponade that occurred two weeks after implantation of a permanent pacemaker. Echocardiography confrmed the presence of a moderate amount of newly‑formed pericardial efusion. The second patient underwent PCI for the right coronary artery. How‑ ever, despite an uneventful procedure, the patient experienced dyspnea, tightness of chest and cold sweats, and bradycardia two hours after the procedure. Echocardiography fndings, which showed a moderate amount of newly‑ formed pericardial efusion, suggested acute cardiac tamponade, and compromised hemodynamics. Both patients recovered with medication. Conclusion: These cases illustrated that PCIS can occur after minor myocardial injury, and that the possibility of PCIS should be considered if there is a history of possible cardiac insult. Keywords: Pericarditis, Injury syndrome, Pacemaker, Coronary intervention Background diferential diagnosis. Here, we describe two typical cases Dressler syndrome, also known as post cardiac injury of PCIS. syndrome (PCIS), is characterized by the development of pericarditis with or without pleural efusion, days to Case presentation weeks after a myocardial infarction. In addition to myo- Illustrative Case #1 cardial infarction, PCIS has been shown to be induced A 78-year-old man diagnosed with sick sinus syn- by pericardiotomy and blunt trauma, as well as by minor drome received a permanent pacemaker (DDDR-MRI insults to the heart, such as coronary intervention, Medtronic [ventricular lead (MEDTRONIC cistofx insertion of pacemaker leads, or radiofrequency abla- 5076–58 cm); atrial lead (MEDTRONIC cistofx 5076– tion [1–5]. However, since PCIS induced by insertion 52 cm)]). Te procedure itself and the post-procedure of a pacemaker or by coronary intervention is relatively screening were both uneventful. Te wound was clean, uncommon, it is possible to miss this as an important and there was no evidence of pneumothorax or hemo- thorax on the chest X radiography (CXR). Te patient *Correspondence: [email protected] was discharged on the second day after the procedure. †MS Huang and YH Su have contributed equal However, the patient complained of a productive 1 Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng cough during a routine outpatient clinic follow-up visit Kung University, 138 Sheng‑Li Road, Tainan 704, Taiwan conducted a week after the procedure. Laboratory fnd- Full list of author information is available at the end of the article ings showed a decrease in hemoglobin level from 10.9 © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Huang et al. BMC Cardiovasc Disord (2021) 21:394 Page 2 of 6 to 8.9 mg/dL. A CXR revealed newly developed border- without dynamic diastolic collapse of the right ventricle line cardiomegaly and bilateral blunting of the diaphrag- (RV). matic angle. Pacemaker interrogation results showed The patient was treated for congestion, and admin- normal threshold and impedance of both leads. An istered a nitrate infusion. The patient also received evaluation performed at fourteen days after the proce- empirical treatment with antibiotics since the low- dure showed evidence of orthopnea, dyspnea upon exer- grade fever was suggestive of an infection. The workup tion, and a minor fever (38 °C). Physical examination for pleural effusion showed evidence of transudate, showed engorgement of the jugular vein, basal crackles and culture results for microorganisms tested were over the bilateral lower lung felds, and pitting edema in negative, including common aerobic and anaerobic both legs. Laboratory data revealed worsening anemia bacterium as well as mycobacterium tuberculosis. (decrease in hemoglobin level from 8.9 to 7.7 mg/dL), Based on concerns about lead migration or protrusion- high NT-proBNP (1610 pg/ml), and hyponatremia (Na: induced hemopericardium, the patient was subjected 115 meq/L, Osmo: 267), but no leukocytosis or wors- to chest computed tomography (CT), and no protru- ening of renal function. An echocardiography revealed sion was detected (Fig. 1). Additionally, the density moderate pericardial efusion (maximal thickness 1.5 cm) of pericardial effusion was 20 Hounsfield unit (HU), Fig. 1 Case 1 series images. a One day after implantation of pacemaker; b signifcant increase in cardiothoracic ratio at fourteen days after implantation; c CT scan showed no lead perforation, no pericardial efusion or pleural efusion; d After steroid treatment; e Recurrent PCIS, two weeks after completion of the steroid course; f Fourteen days after treatment with steroids and colchicine Huang et al. BMC Cardiovasc Disord (2021) 21:394 Page 3 of 6 which also did not support the possibility of hemo- Illustrative Case #2 pericardium. There was a limited improvement in the An 82-year-old male with a history of chronic atrial patient’s condition following several days of treatment, fbrillation (CHADS2: 3) was treated with rivaroxaban. and echocardiography showed no worsening of peri- Te patient presented at the cardiology clinic with cre- cardial effusion (thickness around 1.1 cm). Based on scendo angina, and was reviewed with a coronary angi- a suspicion of PCIS, the patient was prescribed pred- ography examination, which showed signifcant focal nisolone (30 mg/day initially), after which there was a stenosis at the orifce of the right coronary artery (RCA) dramatic improvement of his condition. The dosage of (Fig. 2). Te patient was subjected to percutaneous coro- prednisolone was gradually tapered off to 20 mg/day nary intervention (PCI), where a Xience Xpedition stent after a week, 20 mg to 10 mg/day after two weeks, and (3.5/15 mm) was deployed at the orifce. Te procedure the patient was maintained on 10 mg/day for 8 weeks. was uneventful, and the fnal angiogram showed good Although the CXR returned to baseline after com- RCA fow, and no evidence of perforation, dissection, or pletion of the steroid treatment (Fig. 1), there was a extravasations (Fig. 2). recurrence of pleural effusion, leading to the resump- However, two hours after the procedure, the patient tion of low dose prednisolone treatment in addition to developed cold sweats, tightness in the chest, and hemo- colchicine treatment. The patient recovered well after dynamic compromise along with bradycardia (50 bpm) this treatment. and hypotension (systolic blood pressure: 70–80 mm Hg). Although a complete electrocardiography (ECG) Fig. 2 Case 2 series images. a Normal chest radiography (CXR) before intervention; b White arrow: narrow portion of right coronary artery orifce; c Stent deployed at orifce, no extravasation found; d CXR at 2 h after stent deployment; e chest computed tomography (CT) showed no dissection, but a signifcant amount of pericardial efusion; f Follow‑up echocardiography after steroid treatment showed decreased pericardial efusion without signs of RV collapse Huang et al. BMC Cardiovasc Disord (2021) 21:394 Page 4 of 6 showed no abnormalities, echocardiography showed new In our frst patient, the cause of heart failure, pericar- pericardial efusion (thickness 1.1–1.5 cm) with RV early dial efusion and pleural efusion was initially unknown, diastolic collapse. Tis was immediately followed by a and device interrogation showed normal results. Te repeat coronary angiography, which showed good RCA patient had low-grade fever without leukocytosis. Blood fow without any extravasation, perforation or thrombo- culture and thoracocentesis were performed in order sis. A chest CT scan with contrast showed no aortic dis- to rule out infection and the possibility of hemothorax. section, and the density of pericardial efusion suggested Although there was no progression of pericardial efu- hemopericardium (HU: 40) (Fig. 2). In addition to vaso- sion or signs of tamponade on echocardiography, chest pressors which were administered to stabilize the hemo- CT scan was performed to make sure there was no per- dynamics, the patient was also prescribed a 50 mg dose foration of the pacing leads, or venous thrombosis by of hydrocortisone for PCIS. Tere was an improvement the leads. Tis procedure was similar to a previous study in the patient’s condition on the second day and all vaso- by Farbod et al. [8], where a diagnostic fow chart was pressors was discontinued in 18 h.