From The Suendborg County Hospital, Denmark. Medical Depart- ment. (Physician-in-Chief: W . Thune Andersen, M . D.)

PEltICARDITIS SICCA JUVENILIS BENIGNA

BY W. Thune Andersen. M. D.

‘Ihe significance of the various murmurs heard in the stetho- scopy of the heart has become rather secondary since X-rays and electrocardiography have provided better means of apprais- ing the state of the organ. It has long been realized that but little importance was to be attached to systolic murmurs. Dia- stolic and praesystolic murmurs are undoubtedly of more con- sequence, but here again it has often been the experience that they are to be heard in people with an apparently sound heart. On the other hand, a murmur that will always make the examining physician suspicious is the pericardial friction sound. When this is heard it will be usual to assume a serious infection, which males prognosis uncertain; even if the infection is cured there will be reason for fearing the development of a Symphysis pericardii later on. And so, on going through the text-books on the subject of acute pericarditis one finds that its prognosis is set up with all possible reserve. Rheumatic infection is the cause advanced first and foremost for acute pericarditis, but it is quite likely to occur as a complication to any form of infec- lion. Again, pericarditis of a non-infectious nature is nothing uncommon, i.a. as one of the elements in polyserositis. It may be observed in uraemia or in coronary occlusion. For the sake of completeness I may also mention that it is to be seen in the case of lesions affecting the pericardium and the intrusion of foreign bodies.

As an etiological factor in pericardial affections White states that in a large material the following causes were found:

Pneumonia 34 %, rheumatic fever 28 %, uraemia 11 %, tuber- culosis 10 %, sepsis 5 %, coronary occlusion 3 %, typhoid 2 %, the remaining 7 % being unknown.

48

Hc makes no mention of scarlet fever, though undoubtedly this is sometimes complicated by a purulent pericarditis; but perhaps this may come under the heading of sepsis.

Pericarditis has a predilection for young people between the ages of 10 and 40, presumably because one is most exposed to the severe infections in these years. It is thrice as frequent among males as among females, as several authors confirm, but no reason for this has been adduced.

It would seem, however, that Pericarditis sicca is not always so grave a disease as one would think after perusing the litera- ture. In the course of time I have four times seen attacks of such a benign nature, and with such an identity in the sympto- matologi that I have considered it justifiable to call it Pericard- itis sicca juvenilis benigna. Two of the patients were in the Copenhagen Municipal Hospital third med. Department and Svendborg County Hospital med. Department respectively; the other two were not hospitalized, but I was called in by their doctors and considered hospital treatment unnecessary. For one of the latter I have unfortunately been unable to find the entry in m y case-book and have therefore had to give the details fvom memory.

Case Record I. Male, student, 18 years, Copenhagen Municipal Hospital, 3rd

med. Dept. 7th Sept.-10th Nov. 1934. Had previously been well, except that his appendix was re-

moved when he was 13 years old. The present affection began a few weeks before hospitalization, with pain downwards on the left anterior surface of the thorax; simultaneously there was the phenomenon that in time with the pulse there were loud clicks in the chest, no pyrexia or other symptoms of any kind; in partic- ular he did not feel very unwell. As the pain and the curious sounds continued, he was sent to hospital.

Physical examination: Quite healthy, natural appearance, not ill, normal temperature.

st. cord.: Borders rather difficult to determine, but the heart not considered enlarged. Action regular and like the pulse 72. Sounds muffled, rather distant when patient lying on his back, but when on his left side there is a loud, almost double metallic sound immediately under the stethoscope on a line with the apex. (At later stethoscopic examinations the curious sound is char-

acterizcd as a typical pericardiac friction sound which intensifies with pressure on the stethoscope.)

Steth. pulm.: Slightly weak respiration over the entire left lung, otherwise nothing definitely abnormal.

Abdomen : Natural except for the appendectomy cicatrice. Extremities : Natural. Height: 188 cm. Weight: 71 kg. Urine: normal. S. R.: 4 mm. - 7 mm. - 4 mm., taken three times at 14 days’

Haemoglobin: 92 %. Blood picture: Quite normal. W.R.: -, Mantoux: weakly +. Electrocardiog.: Slight indication of right axis deviation, other-

wise nothing definitely abnormal, especially nothing to suggest myocarditis.

intervals.

X-ray: Heart quite normal. Lungs normal, except that on the left side there was a very small

pneumothorax, a border about 1 cm. wide being visible between the lung and thorax wall; it comprised only the upper third of the lung, however.

Diagnosis: Pneumothorax spontanca. Heart normal. On later skiagrams the pneumothorax disappeared gradually,

whereafter the picture became completely normal. While in the 3rd Dept. he was given no special treatment. In

the course of a month the stethoscopic changes subsided entirely. He was then allowed to get up; was a little tired the first few days, but soon got over it. On discharge he was quite symptom-free.

In 1939 it was reported that during the past five years he had been quite well and had noticed nothing at all from his heart, in spite of hard work (engineering apprentice).

Case Record 11.

Male, 18 years, student. Previously quite well. Suddenly one day in 1935 while at dinner he had a peculiar

sensation in the left side of the chest, “as i f something was burst- ing inside me”, as he put it. Immediately afterwards he heard scraping, sonorous sounds synchronous with the pulse beat, so loud as to be heard by the other members of the family in the room. He did not feel ill, shocked or short of breath, but never- theless was put to bed. His doctor summoned me, and I found the following:

Physical exam. : (luite licalthy, natural appearance, tall but rather slender.

Einar Meulengrnclit 4

Steth. cord. : Almost corresponding to the apex there were rough, rasping, pericardiac friction sounds which were distinctly intens- ified on pressing the stethoscope hard. The remaining examination revealed nothing abnormal whatever.

Height: 190 cm. Weight: 72 kg. Urine: normal. S.R.: 3 mm. Electrocardiog. : Quite normal. X-ray of heart and lungs: Quite normal. The murmurs subsided in a few days. For safety's sake he was

kept in bed for a time, but as he was then quite symptom-free and not feverish, with a normal S.R. , he was allowed to get up, but warned to be careful.

Since then his heart has never troubled him, and in answer to an inquiry in 1947 I was informed that he is still quite well.

Case Record 111.

Male, 18 years, student. Previously quite healthy, particularly had no heart or lung

symptoms, Without any external cause he had a sudden sensation in the left side of the chest one day, as i f his heart were scraping on something. He did not feel ill, or shocked, but summoned a relative who was a local practitioner. The latter found pericardial friction sounds and called me.

On examination I found a tall but rather slender young man. healthy natural appearance, not unwell or short of breath.

Steth. cord.: Rough pericardiac friction sounds over most of the precordium, otherwise nothing abnormal.

The rest was quite natural. S. R.: 2 mm. Urine : normal. Electrocardiog.: normal , Temp. : normal. X-ray of heart and lungs: normal. A s the case was so very similar to the two previous cases, I pre-

suined to draw an analogous conclusion from them and prognostic- ated a good termination, though I advised him to keep his bed until the murmurs had subsided. I have heard nothing of him since and therefore assume that the course was as in the other cases.

Not having noted his name, I am unfortunately unable to say anything of his present condition.

Case Record 11'.

Male, 18 years, engineering apprentice. Admitted to the Medical Dept., Svendborg County Hospital, from

51

28th August to 12th September 1947. Quite well previously, inocul- ated against Tb. a year ago. Two days before hospitalization and quite without exterior cause, while standing still he felt a pain between the shoulder-blades, radiating from there forward to the left side of the chest. He himself had a sort of impression that he had “strained a muscle”. The doctor called in found pericardiac friction sounds over the heart and therefore had him admitted here.

Physical exam. : Healthy natural, appearance, certainly not ill, no dyspnoea or cyanosis; rather tall and well built. Steth. cord.: Borders normal. At the left sternal margin in the 4th intercostal were distinct, rough friction sounds which were inten- sified on pressing the stethoscope hard, whereby they had a me- tallic, almost gurgling character and could then also be heard by people standing round. Action slightly accelerated, regular, about 90; otherwise condition normal.

Other examinations revealed nothing at all abnormal. Height: 173 cm. Weight: 56 kg. Urine: normal. S.R.: 3 mm. W. R.: -. Haemoglobin: 120 %. Blood picture : normal. Blood pressure: 135/80. Antistreptolysine : twice after a week, just before discharge, com-

pletely normal conditions. While in hospital the murmurs subsided i n the course of eight

days, whereafter he was quite symptom-free. Electrocardiograms were taken every other day, 1 0 in all, and showed quite normal conditions.

The sedimentation rate on discharge was 2 mm. X-ray of heart and lungs showed quite normal conditions both

on adniission and on discharge. The temperature was normal all the time. The pulse cnrve during

the first few days was between 80 and 100, afterwards slightly below 80.

Discharged in a state of complete health.

Here then are four cases of pericardiac friction sounds with an acute onset. The following circumstances were common to all four: 1) They were all male patients. 2) They were all about 18 years of age. 3) They were all over medium height, in fact two were con-

4 ’

52

siderably over, and the allack came at a time when they were growing fast.

4) In all cases the attack subsided, apparently without leaving any trace.

5 ) No trace of infection was found in any of the patients. Temperature was normal, general condition especially good, sedimentation rate normal; Antistreptolysine was tesled only on No. 4, but it was normal.

6) The murmurs were unusually loud and sonorous. On account of these common characterislics in the four case

records I consider it justifiable to draw the conclusion that the cause of the friction sounds was not pericarditis proper, but rather a ruplure brought aboul by displacement through thr marked and rapid growth. This rupture must have brought about an unevenness in the pericardium, thus giving rise to the friction murmur. 11 is curious that in 110 case is there anamnestic information of the attack starting in conjunction wilh physical exertion; on lhe contrary, in one case a1 any rate il came while the patient was sitting quietly at dinner. One of the patients, No. 1, had a complication, a slight spontaneous pneumolhorax. In view of the above argumenls, which also apply l o the last-named patient, i t must be said that this provides additional support for the lheory of a rupture as the etiological factor. In Case 1 there was also a ruplure of the pleura.

Prognosis seems lo be good, at any rate for Lhe period of oh- servalioii hitherto possible. Two of the patients were quite withoul syniplonis for five and twclve years after. Naturally, nolhing can be said of thc prospect oC symptoms of Symphysis pericardii later in life, but it is hardly probable when they have been quite symptom-free such a long time. Presumably, there- fore, i t is justifiable to characterize the affeclion as Pericarditis sicca juvenilis benigna.

Conclusion. ‘The author describes four cases of young, rapidly growing men with pericardiac friction sounds with an acute onset, bul otherwise no symptonis whatever, especially no signs of infection. On account of their uniforin course the author believes it justifiable to set then1 up as a special disease under the name of Pericarditis sicca juvenilis bcnigna.