**3. Clinical picture**

Perimyocarditis has a wide spectrum of presentation with some cases being asymptomatic, some suffering from symptoms of the preceding viral illness and some presenting with acute heart failure and cardiogenic shock as in cases with fulminant myocarditis. 60% of the cases have constitutional symptoms including fever, arthralgia, malaise and chills. In 35% of the cases, there is chest pain which is usually mild, persistent, stitching, worsens with deep inspiration or coughing and radiates specifically to the trapezius ridge. Chest pain can sometimes be severe raising the suspicion of myocardial infarction which is always in the differential. Patients may also present with palpitations, syncope, Stokes-Adams attacks or sudden death due to arrhythmias including ventricular tachycardia and variable degrees of conduction abnormalities. Careful history taking is mandatory with specific reference to the patient's age, underlying medical problems including diabetes mellitus, hypertension, dyslipidemia, smoking history, positive family history of coronary artery disease and cocaine abuse that can place the patient at risk for myocardial ischemia. Clinical examination may be irrelevant with non-specific features as fever and tachycardia being the only positive clinical findings. Other clues in examination include a pericardial friction rub, however, only a minority of patients have pericardial rub on exam which tends to be transient and variable [26, 27]. A study of a cohort of patients with acute pericarditis confirmed poor sensitivity of a pericardial friction rub, which was found in only 35% of the cases [26]. Signs of decompensated heart failure (e.g. S3 gallop, elevated jugular venous pressure, lower limb edema and pulmonary congestion) can be detected in patients with fulminant myocarditis.
