To the Editor: 

We read with great interest the case report by Divoky and Wilford¹ published in the January 2014 issue of The Journal of the American Osteopathic Association. The authors described a case of an intermittent relapsing form of recurrent myopericarditis that appeared to have a seasonal correlation. The authors referred to it as seasonal recurrent myopericarditis. 

Although it was an interesting and well-written report, we would like to highlight our observations about the case. The first and subsequent symptoms of recurrent pericarditis can often occur at variable times after the initial attack, but symptoms usually recur within 18 months.^2,3 Arbitrarily, a 6-week period is used to differentiate 2 forms of recurrent pericarditis: intermittent relapsing form (in which patients may have symptom-free intervals of more than 6 weeks without therapy) and incessant form (in which discontinuation of anti-inflammatory therapy always results in symptoms within 6 weeks).³ The use of corticosteroids as a first-line treatment in acute pericarditis is one of the strongest risk factors for future episodes of relapsing pericarditis and reduces the efficacy of colchicine.^3-6 The early use of steroids may augment viral replication, thus causing increased viral antigen exposure in viral or idiopathic pericarditis and thus increasing the risk for relapsing pericarditis.^3-6 In the presented case,¹ the patient was discharged while taking oral steroids (for unclear reasons) after his first attack of viral myopericarditis, despite clinical improvement with nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine. The oral steroids could have triggered the patient's recurrent symptoms. With the exception of underlying connective tissue disease, ongoing steroid use, pregnancy, or previously demonstrated failure of the standard therapy (NSAIDs or colchicine), steroids are rarely the initial choice of therapy in patients with acute pericarditis.⁴ 

Additionally, patients with previous herpes infection (especially herpetic pericarditis) can have symptoms similar to recurrent pericarditis (similar to Mollaret meningitis), especially patients with an immunocompromised status. Although herpetic pericarditis appeared unlikely for the described patient for the reasons the authors described, this possibility should be remembered. 

The authors stated, “From an immunologic standpoint, the seasonal aspect of this case does not necessarily support a viral etiologic process because immunity would develop after the first illness—unless a different organism was responsible each time.”¹ We disagree with this statement. Idiopathic pericarditis is often viral in nature, and at least 15% to 20% of patients experience a recurrence.³ Another example of a potential viral etiologic process is a reactivation of the herpes infection in patients with herpetic pericarditis. 

One additional differential consideration to the presented case is drug-induced myopericarditis, as suggested by the paroxysmal use of cannabis in this patient (confirmed with positive drug screen results). Cannabis is a known potential trigger for the recurrence of pericarditis by inducing inflammation.⁷ We believe that it is possible that a combination of these triggers may have played a role in the patient's recurrent symptoms, rather than a mere seasonal preponderance as defined.