I had stabbing chest pains in the left side of my upper chest that got worse over two days and did not get better with rest. At one point a shooting pain radiated from below the breastbone up toward my left shoulder. Two different on call Kaiser doctors told me to get to the nearest ER and get checked. The non-Kaiser ER did blood tests, an ECG and a chest x-ray and ruled out heart attack. The ER doctor recommended getting an echocardiogram and wearing a heart monitor. A Kaiser doctor the following day stated that pericarditis is ruled out by having normal white blood cell counts, by having a spot you press on at the base of the breastbone which causes the pain to recur in the left chest, and by the stabbing pains not getting worse with exercise. For these reasons, he declined to order the echocardiogram. I believe this doctor is incorrect after doing the research for this article. While generally true, everything I’ve read says there are exceptions. In any case, I am left with unexplained sharp chest pains that felt pretty scary. This article explores the possibility that this is caused by an infection of my heart lining known as pericarditis.
Emergency Room, First Stop
Get to an emergency room if a doctor recommends that you do so, or if you feel that you may be having a life threatening emergency. There are times and situations, however, where no doctors are available, or when all available doctors are stumped. Diagnosing and treating chest pain without access to medical professionals requires a careful approach based on available knowledge and resources.
Sharp Pains? Consider the Options
If the ER has ruled out critical causes of chest pain such as pancreatitis, gall stones, cancer, a hernia and a heart attack (congestive heart failure due to blockages, etc.) recognizing the symptoms of pericarditis and understanding its various causes and treatments is necessary for effective management. While pericarditis is often not life-threatening, timely intervention is necessary to address potential complications that could arise if left untreated.
What rules out Gall Stones?
Gallstones are unlikely to cause sharp, intermittent pain in the left upper chest that does not improve with rest due to several factors. Typically, gallstone-related pain occurs in the right upper quadrant of the abdomen, often triggered by fatty meals and accompanied by symptoms like nausea or bloating. The absence of these symptoms, along with the atypical location and characteristics of the pain, suggests other causes such as cardiac issues, musculoskeletal conditions, or gastrointestinal problems. Additionally, diagnostic imaging that shows no gallstones further rules them out as a potential source of the pain. Left upper chest pain is more commonly associated with cardiac issues (e.g., angina or pericarditis), musculoskeletal conditions (e.g., costochondritis), gastrointestinal problems (e.g., acid reflux), or pulmonary issues (e.g., pleuritis).
What Rules Out A Hernia?
To rule out a hernia as the cause of sharp, intermittent pain in the left upper chest that does not improve with rest and is not worsened by exercise, but is sometimes triggered by position, several factors should be considered. Hernia-related pain typically worsens with physical activity and is often accompanied by symptoms like heartburn or regurgitation, which are absent in this case. The positional nature of the pain suggests musculoskeletal issues rather than a hernia, as hernias usually present with more consistent discomfort. Other potential causes of sharp pains that come and go in the left upper chest and may radiate from a lump below the sternum include angina (chest pain due to reduced blood flow to the heart), pericarditis (inflammation of the heart’s outer lining causing sharp pain that may worsen when lying down or breathing deeply), pulmonary embolism (a blockage in a lung artery causing sudden, sharp chest pain and shortness of breath), gastrointestinal issues like gallbladder disease or pancreatitis (which can cause referred pain to the chest), and musculoskeletal pain such as costochondritis or muscle strain. A thorough medical evaluation is essential to rule out serious conditions, including cardiac issues. While GERD can likely be ruled out due to the absence of related symptoms, a hernia cannot be definitively excluded without further diagnostic testing.
What Rules out GERD?
There is zero pain with drinking, eating, or burping, which makes gastroesophageal reflux disease (GERD) unlikely, as GERD is commonly associated with symptoms such as heartburn, regurgitation, and discomfort during or after eating or burping.
What Rules Out Pancreatitis?
What Rules Out Pulmonary Embolism?
What Rules out Musculoskeletal Pain (Eg. Costochondritis or Muscle Strain)?
What is Pericarditis?
The pericardium, originating from the Greek words περί (meaning “around”) and κάρδιον (meaning “heart”), is a thin fibroelastic sac that encases the heart and the roots of the major blood vessels. It comprises two layers: an inner serous visceral layer and an outer fibrous parietal layer. Under normal physiological conditions, the pericardial cavity contains between 10 mL and 50 mL of plasma ultrafiltrate, known as pericardial fluid. Inflammation of this pericardial sac is referred to as pericarditis.
Diagnosis of Pericarditis
Main Symptoms
Pericarditis is an inflammation of the pericardium, the protective sac surrounding the heart. The symptoms can vary depending on the type (acute or chronic) and severity of the condition. Here is a comprehensive list of symptoms associated with pericarditis:
– Chest Pain: This is the most common symptom, often described as sharp, stabbing, or aching. The pain may:
– Be located in the center or left side of the chest.
– Radiate to the neck, shoulders (especially the left), and abdomen.
– Worsen when lying down, breathing deeply, swallowing, or coughing.
– Improve when sitting up or leaning forward[26][27][28][30].
Additional Symptoms
– Fever: A raised body temperature may occur[26][27].
– Cough: A dry cough is often present[27][28].
– Difficulty Breathing: Shortness of breath may be experienced, particularly during exertion[3][6].
– Fatigue: Extreme tiredness or weakness is common[27][28].
– Heart Palpitations: Sensations of a racing or fluttering heart may occur[27][28].
– Muscle Aches and Joint Pain: Generalized aches can accompany pericarditis[27][31].
– Nausea: Some individuals may feel nauseous[27].
– Swelling: Fluid retention can lead to swelling in the legs, ankles, or abdomen, especially in cases of constrictive pericarditis[32][33].
Severe Symptoms
In more severe cases, symptoms can escalate to include:
– Dizziness or Fainting: Indicating possible complications such as low blood pressure[29][31].
– Chest Tightness: This may mimic heart attack symptoms and requires immediate medical attention if accompanied by other severe symptoms[30].
The symptoms of pericarditis according to Kaiser Permanente[12] primarily include sharp pain in the center or left side of the chest. This pain may radiate to the shoulder blade and can be described as dull for some individuals. It typically worsens when lying down or taking deep breaths and lasts for hours or days without improvement during rest. In addition to chest pain, other symptoms may include mild fever, weakness, and a general feeling of fatigue.
It is crucial for individuals experiencing these symptoms to seek medical advice promptly, especially if they resemble those of a heart attack.
Does No Pain on Lying Down Rule out Pericarditis?
No, depite my being turned down by Kaiser for an echocardiogram because the dotor in his 26 years of practice was certain that you can’t have pericarditis without pain on lying down, the absence of pain when lying down does not definitively rule out pericarditis. While it is common for individuals with pericarditis to experience worsened chest pain when lying flat, this symptom can vary among patients.`
- Chest Pain Characteristics: Pericarditis typically causes sharp, stabbing chest pain that may worsen when lying down or taking deep breaths. However, some patients may not experience this specific symptom. Who says this? Who is contradicting my Kaiser doctor’s 26 years of expertise?
This https://www.healthline.com/health/how-to-sleep-with-pericarditis
and this https://www.nidirect.gov.uk/conditions/pericarditis
and this https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pericarditis - Variability in Symptoms: Symptoms can differ based on the individual and the underlying cause of the pericarditis. Some may find relief when lying down or may not have significant pain at all
How Common Is It?
According to one article by Johns Hopkins Medicine, pericarditis is “not very common,” which can make diagnosis challenging for some healthcare providers. Except it is fairly common. It’s most common in men (assigned male at birth) who are between the ages of 16 and 65. An estimated 28 people per 100,000 develop pericarditis each year according to clevelandclinic.org[20].
How is it Evaluated by Doctors?
According to Johns Hopkins Medicine, diagnosing pericarditis may require a comprehensive evaluation that includes a battery of tests such as blood tests, chest X-rays, electrocardiograms (ECGs), computed tomography (CT) scans, magnetic resonance imaging (MRIs), and echocardiograms. The diagnostic process can be difficult for patients, and in some cases, delays in appropriate treatment can lead to complications.
Long Term Lack of Treatment
According to the Frankel Cardiovascular Health Center at the University of Michigan, when the pericardium remains inflamed for more than a few months without proper treatment, the two membranes of the pericardium can fuse together, thicken due to scar tissue, and stick to the heart wall. This can interfere with the ability of the left and right sides of the heart to fill with blood adequately. If left untreated, permanent damage man result in the need for surgery to remove the pericardium[11]. Where patients experienced significant damage to the pericardium by the time they received the correct treatment plan, necessitating open heart surgical intervention to remove it.
Causes of Pericarditis
According to the Mayo Clinic, while pericarditis can cause significant discomfort and complications if left untreated, it is typically manageable with appropriate treatment. The inflammation is often caused by viral infections but can also result from bacterial infections, autoimmune diseases, or other underlying conditions. Pericarditis can arise from various causes, including:
1. Viral Infections: The most common cause of pericarditis is viral infections such as those caused by influenza, echovirus, or Coxsackie virus.
2. Bacterial Infections: Less commonly, bacterial infections can lead to pericarditis and require antibiotic treatment.
3. Autoimmune Disorders: Conditions like rheumatoid arthritis or lupus can cause inflammation of the pericardium.
4. Post-Myocardial Infarction: Pericarditis may occur after a heart attack (post-myocardial infarction syndrome).
5. Trauma or Injury: Physical injury to the chest can also lead to pericarditis.
6. Cancer: Cancer that spreads to the pericardium can cause inflammation.
Do Normal Blood Counts Rule Out Pericarditis?
Acute pericarditis, the most prevalent pericardial syndrome encountered in clinical practice, is diagnosed when at least two of the following criteria are met: chest pain, a pericardial friction rub, characteristic ECG changes (such as new widespread ST elevation or PR depression), or the presence of pericardial effusion. Supportive findings may include elevated inflammatory markers like white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), as well as imaging evidence of inflammation. Importantly, normal blood counts do not rule out pericarditis; while elevated inflammatory markers are common in the condition, their absence does not definitively exclude the diagnosis. Thus, while abnormal blood counts can help support the diagnosis, normal results do not negate it.
Treatment Options
The treatment for pericarditis depends on its underlying cause and severity:
1. Rest and Activity Limitation: Patients are often advised to rest until symptoms improve and any fever subsides. Limiting physical activity helps reduce strain on the heart.
2. Medications for Pain Relief:
– Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Commonly prescribed NSAIDs include ibuprofen or aspirin to alleviate pain and reduce inflammation.
– Colchicine: This medication may be used alongside NSAIDs to enhance symptom relief and decrease recurrence risk.
3. Corticosteroids: If symptoms persist despite NSAID and colchicine treatment, low to moderate doses of corticosteroids like prednisone may be prescribed. These are usually reserved for patients who cannot tolerate NSAIDs or have conditions such as autoimmune diseases.
4. Antibiotics: If bacterial infection is identified as the cause of pericarditis, appropriate antibiotics will be prescribed.
5. Procedures for Complications:
– Pericardiocentesis: This procedure involves inserting a needle or catheter into the chest wall to drain excess fluid from around the heart if fluid buildup (pericardial effusion) occurs.
– Pericardiectomy: In cases of constrictive pericarditis where symptoms are severe and persistent, surgical removal of part or all of the pericardium may be necessary.
6. Long-Term Management: Chronic or recurrent cases may require ongoing treatment with NSAIDs or colchicine for an extended period.
Prognosis for Pericarditis
The prognosis for pericarditis, particularly acute idiopathic pericarditis, is generally very favorable. According to Kaiser Permanente, most cases of pericarditis resolve on their own within a couple of weeks if there are no complications. Most patients with acute pericarditis experience a full recovery, with less than 0.5% at risk for long-term complications such as constrictive pericarditis[21][22]. However, untreated pericarditis can lead to chronic conditions or serious complications affecting heart function. Symptoms may last from one to three weeks for acute cases, while chronic pericarditis persists for three months or longer.
Testing for Lyme Disease
Pericarditis can be cause by different microbes. If you have a history of tick bites you may want to fule out Lyme disease as a cause. Some resources are available and diagnostic testing may help confirm Lyme pericarditis, however, early tests may yield false negatives. Imaging techniques such as echocardiograms can assess heart function and detect pericardial effusion, while cardiac MRI can provide more detailed information about inflammation.
Is Pericarditis Ruled Out by No Exercise Problems?
While the absence of worsening pain during brisk walking may suggest that pericarditis is less likely, it does not completely rule out the condition. Each patient’s experience with pericarditis can vary significantly. Some individuals may not experience increased pain during physical activity, while others might find that even mild exertion aggravates their symptoms. This contradicts what a Kaiser doctor told me. The lack of worsening pain on exercise was his reason for not ordering an echocardiogram which the non-Kaiser ER doctor said I should get.
Pericarditis Pain vs Angina
Rest makes angina better, but this is not the case for pericarditis. I rested for hours and the stabbing pain was still with me, coming and going. Resting does not alleviate the pain associated with pericarditis, which can persist despite hours of rest and may come and go. Angina typically presents as a feeling of pressure or squeezing in the chest, which may also radiate to the arms, shoulders, neck, jaw, or back. Angina pain is often relieved by rest or the use of nitroglycerin. This type of chest pain is usually related to insufficient blood flow to the heart muscle due to coronary artery disease and tends to occur during physical exertion or emotional stress.
Pericarditis Pain vs Myocarditis
Both of these are types of inflammation in your heart, but they’re in different places. Myocarditis is in your heart muscle. Pericarditis happens in your pericardium (the lining around your heart). Most often, a virus causes myocarditis and pericarditis. Both can give you chest pain, but with pericarditis, your chest pain should feel better when you sit up and lean forward. With myocarditis, you’ll usually feel tired and weak.
Detecting Pericarditis with a Stethoscope
A stethoscope can be an essential tool for diagnosing pericarditis by identifying a specific sound known as a pericardial friction rub. This sound occurs when the inflamed layers of the pericardium—the sac surrounding the heart—rub against each other. It is often described as scratchy, grating, or squeaking, similar to the sound of rustling leaves or creaking leather.
Acute pericarditis, the most common pericardial syndrome in clinical practice, is diagnosed when at least two of the following criteria are met: chest pain, a pericardial friction rub, characteristic ECG changes (such as new widespread ST elevation or PR depression), or the presence of pericardial effusion. Supportive findings include elevated inflammatory markers like white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), as well as imaging evidence of inflammation. However, normal blood counts do not rule out pericarditis, as the absence of elevated markers does not definitively exclude the condition. While abnormal blood counts can support the diagnosis, normal results do not negate it.
How to Listen for a Pericardial Rub
To detect a pericardial rub, place the diaphragm of the stethoscope over the left sternal border or apex of the heart. Ask the patient to sit up, lean forward, and briefly hold their breath during expiration—this position brings the heart closer to the chest wall, making the rub easier to hear. The rub is often loudest during specific phases of the cardiac cycle and may have three distinct components: one during atrial systole, one during ventricular systole, and one during early diastole. It is important to note that a pericardial rub can disappear if the condition worsens or improves, reflecting changes in inflammation or fluid dynamics.
Why Listening for a Pericardial Rub Matters
A pericardial rub is a pathognomonic sign for acute pericarditis and serves as one of its key diagnostic criteria. Although its intensity and location can vary, detecting this sound is highly specific for pericarditis and can aid in diagnosis without advanced tools. However, it should be considered alongside other symptoms such as chest pain and shortness of breath for an accurate assessment. Effective use of a stethoscope can help identify pericarditis early, enabling timely intervention even in resource-limited settings.
Does Lack of a Pericardial Rub Rule Out Pericarditis?
No, the absence of a pericardial rub does not rule out pericarditis. While it is highly specific and pathognomonic for acute pericarditis, it is present in only 35% to 85% of cases, depending on factors such as the timing of the examination and the examiner’s expertise. Additionally, the rub may be absent if the patient’s condition worsens or improves significantly. Therefore, clinical evaluation should consider other diagnostic criteria and supportive findings when a rub is not detected.
Treatment of Lyme Pericarditis
Immediate Antibiotic Therapy
If Lyme pericarditis is suspected, it is crucial to initiate empirical treatment immediately—even before test results are available. The recommended first-line treatment includes intravenous (IV) ceftriaxone at a dosage of 2 grams once daily for 14 to 21 days. If ceftriaxone is unavailable, alternatives include IV cefotaxime or high-dose penicillin G.
Oral Antibiotics
If intravenous treatment is not feasible, consider prescribing oral antibiotics such as doxycycline at a dosage of 100 mg twice daily, amoxicillin at 500 mg three times daily, or cefuroxime at 500 mg twice daily for a similar duration.
Symptomatic Relief
Symptomatic relief can be achieved using non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen at a dosage of 400 mg every eight hours to alleviate pain and inflammation. Additionally, colchicine at 0.6 mg twice daily may also be beneficial in reducing inflammation.
Monitoring
Continuous monitoring of heart function is essential through self-assessment of symptoms. Regular checks of heart rate and rhythm should be conducted while remaining alert for signs of worsening conditions such as increased shortness of breath or severe chest pain.
Lyme Emergency Measures
If severe complications arise—such as significant bradycardia or heart block—temporary pacing may be necessary if resources allow.
Lyme Prognosis and Follow-Up
Most patients respond well to antibiotic therapy, with symptoms resolving within one to six weeks. It is crucial to continue monitoring for any recurrence of symptoms after completing antibiotic treatment. If initial tests were negative but clinical suspicion remains high, repeating serological testing after a few weeks may be warranted.
Real World Lyme Experience
Unfortunately, the tests used for Lyme detection are notoriously bad. Zeus Scientific, the maker of the only approved test kits used by every doctor in the USA states on the package insert that some people never make antibodies, therefore, the test can not be used to rule out Lyme disease. This is exactly what Kaiser Pemanente does, however. They ignore the tick bites, the rash, the clinical symptoms, everything except the bad test which lets them avoid long term treatment of this difficult disease after it has taken hold. Late stage Lyme disease can include symptoms such as pericarditis.
Late Stage Lyme Carditis
Late-stage Lyme disease, also known as late disseminated Lyme disease, can develop 6 to 36 months after the initial tick bite and presents with a variety of symptoms, including pericarditis. Common manifestations include tinnitus, stiff sore neck and upper back, joint pain and swelling, skin changes, and neurological complications such as fatigue, memory problems, or tingling, burning or numbness in the extremities. In North America, arthritis is a frequent symptom, while cardiac issues like palpitations and chest pain may arise from Lyme carditis. These cardiac complications make it crucial for individuals exposed to Lyme disease to undergo an electrocardiogram (ECG) to detect potential heart block, a condition that can be fatal if untreated. Although rare, sudden cardiac death has been reported in some cases of Lyme disease. Early recognition and management of symptoms are essential to prevent severe outcomes.
Ruling Out Cancer
A lump below the sternum that radiates pain into the left shoulder raises concerns about various underlying conditions, including the possibility of cancer. While many lumps in this area can be benign, such as lipomas or hernias, it is crucial to consider more serious causes, including chest wall tumors or lymphomas. Symptoms accompanying the lump, such as persistent pain, weight loss, or changes in appetite, can further indicate the need for investigation. Diagnostic imaging, such as CT scans or MRIs, alongside a thorough physical examination and possibly a biopsy, may be necessary to determine the nature of the lump. Given that some cancerous lumps can feel similar to benign growths, consulting a healthcare professional for an accurate diagnosis is essential to rule out malignancy and ensure appropriate management.
Conclusion
It is essential for individuals experiencing symptoms consistent with pericarditis to seek medical attention promptly. Early diagnosis and management can significantly improve outcomes and prevent long-term complications associated with this condition. This guide provides essential steps for diagnosing and managing Lyme caused and other pericarditis in resource-limited situations. Recognizing symptoms early and initiating appropriate treatment can significantly improve outcomes.
Disclaimer
This article is intended for educational purposes only. It is not a substitute for professional medical advice or treatment. Always consult a healthcare provider for any medical concerns you may have.
Citations
- PMC Article on Lyme Carditis
- IDSA Guidelines on Lyme Disease
- CDC on Lyme Carditis
- UPMC on Lyme Carditis
- JACC Journal on Diagnosis and Treatment
- Mayo Clinic on Pericarditis
Read More
[1] https://nuhw.org/kaiser-dont-deny/patient-stories/
[2] https://www.kaiserthrive.org/2007/11/03/how-kaiser-permanente-treats-people-who-complain/
[3] https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/community-providers/ncal/2022/Member-Rights-and-Responsibilities.pdf
[4] https://www.meaction.net/2017/02/03/pwme-people-with-me-are-being-murdered-by-neglect/
[5] https://www.reddit.com/r/KaiserPermanente/comments/1djsbb5/has_anyone_else_experienced_kaiser_doctors_not/
[6] https://www.reddit.com/r/KaiserPermanente/comments/1htf9q2/urgent_a_warning_to_every_parent_patient_in_the/
[7] https://www.reddit.com/r/KaiserPermanente/comments/1c4w744/doctor_ignoring_you_experience/
[8] https://www.adirondackdailyenterprise.com/opinion/guest-commentary/2025/01/troubling-symptoms/
[9] https://www.hopkinsmedicine.org/health/conditions-and-diseases/pericarditis
[10] https://www.mayoclinic.org/diseases-conditions/pericarditis/symptoms-causes/syc-20352510
[11] https://www.mayoclinic.org/diseases-conditions/pericarditis/multimedia/treating-pericarditis-video/vid-20139209
[12] https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.pericarditis-care-instructions.uh3891
[13] https://www.heart.org/en/health-topics/pericarditis/treatment-of-pericarditis
[14] https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pericarditis
[15] https://www.mayoclinic.org/diseases-conditions/pericarditis/diagnosis-treatment/drc-20352514
[16] https://my.clevelandclinic.org/health/diseases/17353-pericarditis
[17] https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/pericarditis
[18] https://www.upmc.com/services/heart-vascular/conditions/pericarditis
[19] https://www.bhf.org.uk/informationsupport/conditions/pericarditis
[20] https://my.clevelandclinic.org/health/diseases/17353-pericarditis
[21] https://pmc.ncbi.nlm.nih.gov/articles/PMC6964178/
[22] https://www.ncbi.nlm.nih.gov/books/NBK542284/
[23] https://www.aafp.org/pubs/afp/issues/2014/0401/p553.html
[24] https://medlineplus.gov/pulmonaryembolism.html
[25] https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/pulmonary-embolus
[1] https://www.bupa.co.uk/health-information/heart-blood-circulation/pericarditis
[2] https://www.healthdirect.gov.au/pericarditis
[3] https://www.heart.org/en/health-topics/pericarditis/symptoms-and-diagnosis-of-pericarditis
[4] https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pericarditis
[5] https://www.nhs.uk/conditions/pericarditis/
[6] https://my.clevelandclinic.org/health/diseases/17353-pericarditis
[7] https://www.bhf.org.uk/informationsupport/conditions/pericarditis
[8] https://www.cedars-sinai.org/health-library/diseases-and-conditions/p/pericarditis.html
For Lyme pericarditis, while natural remedies like grapefruit seed extract, echinacea, astragalus, vitamin C, mushroom extracts, Oregon grape root, and ginger root may offer some immune support, they are not substitutes for conventional treatment. The standard approach involves antibiotics, particularly intravenous ceftriaxone, which is considered the first-line therapy for Lyme-related cardiac issues[13].
Natural supplements may help alleviate symptoms or support overall health but should be used cautiously and ideally under the guidance of a healthcare professional. It’s crucial to address Lyme pericarditis with appropriate medical treatment to prevent complications.