How is a presentation of acute exertional chest pain, high fevers, chills, and fatigue in a patient with asthma and obstructive sleep apnea (OSA), who recently drove for 12 hours, consistent with endocarditis, given normal platelet count, no tobacco or alcohol use, and negative urine drug screen (UDS)?

How This Presentation Could Be Consistent with Endocarditis

While acute exertional chest pain with fever in this patient is more likely acute myopericarditis than endocarditis, endocarditis must be excluded with transthoracic echocardiography and blood cultures because both conditions can present with chest pain, high fevers, and constitutional symptoms—and missing endocarditis carries catastrophic mortality risk. 1

Why Endocarditis Is Being Considered (Despite Atypical Features)

Classic Endocarditis Presentations That Match

• High fevers and chills are cardinal features of infective endocarditis, present in 80-90% of cases 1
• Fatigue and constitutional symptoms are common presenting complaints in subacute bacterial endocarditis 1
• Chest pain can occur in endocarditis through multiple mechanisms: septic pulmonary emboli (right-sided disease), coronary artery embolization, or pericardial involvement 1

Why Your Concerns Are Valid

Normal platelet count does NOT exclude endocarditis:

• Thrombocytopenia occurs in only 5-25% of endocarditis cases 1
• Normal platelets are actually the norm in most endocarditis patients 1

Absence of traditional risk factors (no IVDU, negative UDS) does NOT exclude endocarditis:

• Healthcare-associated endocarditis is now more common than IVDU-related cases 1
• Degenerative valve disease, dental procedures, and skin infections are increasingly common sources 1
• The patient's occupation as a healthcare provider may actually increase risk through occupational exposures 1

The More Likely Diagnosis: Acute Myopericarditis

This presentation is MORE consistent with post-viral myopericarditis than endocarditis:

Key Clinical Features Favoring Myopericarditis

• Acute exertional chest pain following a recent viral illness (implied by fever/chills) is classic for myocarditis 2
• Chest pain with fever in a young patient without coronary risk factors suggests inflammatory cardiac disease 2
• Myopericarditis can present with troponin elevation mimicking ACS even with normal coronary arteries 1

The 12-Hour Drive Connection

• Prolonged immobility increases risk for both pulmonary embolism (must exclude) and can precipitate symptoms in underlying inflammatory conditions 1
• OSA is a significant risk factor for cardiovascular complications and may have contributed to symptom onset 3

Immediate Diagnostic Algorithm

Within 10 Minutes of Presentation

1. Obtain 12-lead ECG immediately to identify ST-elevation, widespread ST-elevation with PR depression (pericarditis), or new ischemic changes 1, 4
2. Measure cardiac troponin as soon as possible—elevation occurs in both myocarditis and endocarditis with cardiac involvement 1, 2

Urgent Additional Testing

1. Order blood cultures (at least 3 sets from different sites) before antibiotics if endocarditis is suspected 1
2. Obtain transthoracic echocardiography to assess for vegetations, pericardial effusion, or wall motion abnormalities 1
3. Chest radiography to evaluate for pneumonia, pulmonary emboli, or cardiomegaly 2

Risk Stratification for Pulmonary Embolism

1. Calculate Wells score or apply PERC rule given the 12-hour drive history and OSA (both PE risk factors) 2
2. D-dimer testing if pretest probability warrants, followed by CT pulmonary angiography if positive 2

Advanced Imaging When Initial Testing Is Inconclusive

If myocardial injury is present with nonobstructive coronary arteries:

• Cardiac MRI with gadolinium contrast is the gold standard to distinguish myopericarditis from other causes including MINOCA 1, 2
• CMR can identify myocardial inflammation, edema, and fibrosis patterns specific to myocarditis 2

Critical Pitfalls to Avoid

Do Not Delay Transfer for Additional Testing

• This patient requires immediate ED evaluation by EMS if presenting in an office setting 4
• Delaying transfer to obtain additional testing in the office is classified as Class 3: Harm 4

Do Not Assume Normal Platelets Exclude Serious Pathology

• Normal platelet counts are typical in most endocarditis cases 1
• OSA patients may have altered platelet indices (elevated PDW) but normal platelet counts 5, 6

Do Not Overlook Life-Threatening Causes

• Acute coronary syndrome, pulmonary embolism, aortic dissection, and myopericarditis all present with acute chest pain and fever 1
• The combination of exertional chest pain with high fever mandates exclusion of all immediately life-threatening conditions 1

Disposition

If ECG shows ST elevation, new ischemic changes, or signs of tamponade:

• Arrange immediate transfer by EMS to the emergency department 2
• Do not transport by personal vehicle due to increased mortality risk 4

If myopericarditis is confirmed:

• Treatment includes NSAIDs and colchicine; steroids may be needed for refractory cases 2
• Avoid stress testing until acute inflammation resolves, as acute myopericarditis is an absolute contraindication 7