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Letters to the Editor  |   July 2014
Response
Article Information
Cardiovascular Disorders
Letters to the Editor   |   July 2014
Response
The Journal of the American Osteopathic Association, July 2014, Vol. 114, 533. doi:10.7556/jaoa.2014.106
The Journal of the American Osteopathic Association, July 2014, Vol. 114, 533. doi:10.7556/jaoa.2014.106
We appreciate the comments and expertise of Chhabra et al.1 The interesting aspect of our case2 was the timing of the recurrent symptoms. For 3 consecutive years, the patient received a diagnosis of myopericarditis within the same 4-week period of the calendar year—with a potential fourth episode the following year—and no symptoms in the intervening periods.2 The timing of our patient's recurring symptoms certainly fell inside the usual period for recurring myopericarditis symptoms, which, as Chhabra et al state, is typically within 18 months of the original episode.1,3 However, the recurrent annual presentation such as the one described in our case2 has not been previously reported in the literature, to our knowledge. By definition, seasonal occurrence is occurrence at the same time of the year. An example of a disorder with seasonal occurrence is seasonal affective disorder, which is depression that occurs during a specific season of the year, most often winter.4 On the basis of this definition, we believe our description of “seasonal recurrent myopericarditis” is accurate. 
We agree with Chhabra et al1 that early oral steroid use could have been associated with the recurrent episodes of pericarditis in our patient. After the first incident of myopericarditis, the patient's symptoms partially improved with naproxen. Colchicine was added to the patient's treatment regimen because of the severity of his symptoms. Colchicine, as an adjunct to nonsteroidal anti-inflammatory drugs or aspirin, is the first line of treatment for patients with recurrent pericarditis and, according to recent research, should also be considered for first line of treatment for patients with acute pericarditis.5,6 Ideally, the patient would have continued to receive colchicine after discharge but, unfortunately, he was unable to afford the cost of colchicine and was not eligible for the patient assistance program available at that time. For this reason, the patient was prescribed oral corticosteroids after 2 days of receiving colchicine as an inpatient. 
We also agree with Chhabra et al1 that a viral cause was likely in our patient. Our statement that “the seasonal aspect of this case does not necessarily support a viral etiologic process”2 should be revised, as it was not meant to refute a viral cause of our patient's recurrent myopericarditis. In fact, the seasonal pattern could be related to a virus that circulates in late fall, with subtle antigenic differences each year. 
Chhabra et al1 also proposed cannabis-induced myopericarditis as a potential differential consideration in our case. This consideration is interesting and, although it is a possibility, the patient in our case intermittently smoked cannabis throughout the year, not just during the time of the recurrent myopericarditis, making this cause less likely. A recent publication postulated the causality of recurrent myopericarditis to contaminated cannabis use.7 In that case, the individual smoked contaminated cannabis 48 to 72 hours before the onset of symptoms.7 Our patient intermittently used cannabis and did not have a recurrence of symptoms after every use as described in the mentioned case report. 
In conclusion, the exact etiologic process of our patient's myopericarditis may never be determined. However, the annual recurrence of symptoms within the same 4-week time frame, with no symptoms in the intervening periods, certainly fits the definition of “seasonal.” 
References
Chhabra L, Chaubey VK, Spodick DH. A case of seasonal or recurrent viral myopericarditis? tough to say [letter]! J Am Osteopath Assoc. 2014;114(7):532. doi:10.7556/jaoa.2014.105. [CrossRef] [PubMed]
Divoky L, Wilford RD. A case of seasonal recurrent myopericarditis. J Am Osteopath Assoc. 2014;114(1):52-55. doi:10.7556/jaoa.2014.007. [CrossRef] [PubMed]
Imazio M, Demichelis B, Parrini Iet al. Management, risk factors, and outcomes in recurrent pericarditis. Am J Cardiol. 2005;96(5):736-739. [CrossRef] [PubMed]
Oren DA, Koziorowski M, Desan PH. SAD and the not-so-single photoreceptors. Am J Psychiatry. 2013;170(12):1403-12. doi:10.1176/appi/ajp.2013.13010111. [CrossRef] [PubMed]
Imazio M, Brucato A, Cemin R, et al.  ICAP Investigators. A randomized trial of colchicine for acute pericarditis [published online August 31, 2013]. N Engl J Med. 2013;369(16):1522-1528. doi:10.1056/NEJMoa1208536. [CrossRef] [PubMed]
Imazio M, Belli R, Brucato Aet al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): a multicentre, double-blind, placebo-controlled, randomised trial [published online March 28, 2014]. Lancet. doi:10.1016/S0140-6736(13)62709-09.
Rodríguez-Castro CE, Alkhateeb H, Elfar A, Saifuddin F, Abbas A, Siddiqui T. Recurrent myopericarditis as a complication of marijuana use. Am J Case Rep. 2014;15:60-62. doi:10.12659/AJCR.889808. [CrossRef] [PubMed]