Diagnosis

Pericarditis

Etiology

Causes [zth][ysz][pkg][ynn]

• Idiopathic

• Virus (developed countries): coxsackievirus B, echovirus, adenoviruses, influenza A and B, parainfluenza virus, enterovirus, mumps virus, EBV, CMV, HSV, VZV, HAV, HBV, HCV, HIV, measles virus, RSV

• Bacteria: Tuberculosis (developing countries), Coxiella burneti, Borrelia burgdorferi, Streptococcus, Staphylococcus, Proteus, Escherichia coli, Pseudomonas, Klebsiella, Salmonella, Shigella, Neisseria meningitidis, Haemophilus influenzae, Chlamydia, Mycoplasma, Legionella, Leptospira, Listeria, Providencia stuartii

  Purulent pericarditis: complication of intrathoracic infection or hematologic bacterial spread [zth]

• Fungus: Histoplasma, Aspergillus, Blastomyces, Candida

• Parasite: Echinococcus, Toxoplasma

• Inflammatory: RA, SLE, scleroderma, rheumatic fever, Sjogrens syndrome, Churg-Strauss syndrome, Horton disease, Takayasu disease, Behcet syndrome, sarcoidosis, Mediterranean fever, Crohns disease, ulcerative colitis, Still disease, Amyloidosis

• Metabolic: renal failure, hypothyroidism, myxoedema, hypercholesterolemia

• Cardiovascular: myocardial infarction, Dressler syndrome, aortic dissection, pulmonary arterial hypertension and chronic heart failure

• Cancer: breast, lung, leukemia, lymphoma, pericardial mesothelioma

• Iatrogenic: Postpericardiotomy, radio frequency ablation

• Trauma: direct penetrating injury, indirect radiation, myocardial infarction

• Drug side effects:

  • Lupus-like syndrome: hydralazine, procainamide, methyldopa, isoniazid, anticoagulants, phenytoin

  • Chemotherapy: doxorubin, daunorubicin, cytosine arabinoside, 5-flourouracil, cyclophosphamide

  • Penicillins, amiodarone, methysergide, mesalazine, clozapine, minoxidil, dantrolene, practolol, phenylbutazone, thiazides, streptomycin, thiouracils, streptokinase, p-aminosalicylic acid, sulfa-drugs, cyclosporine, bromocriptine, several vaccines, GM-CSF, anti-TNF

Pathophysiology [ynn]

1. The pericardium is a double-layered, fibroelastic sac separated by 15 to 50 mL of serous fluid

   • Anchoring the heart within the thoracic cavity

   • Barrier against extrinsic infections

   • Reduced friction around the heart

2. Pericardial inflammation often leads to fluid accumulation within the pericardial sac, resulting in a pericardial effusion (serous, hemorrhagic, or purulent)

3. Acute and large pericardial effusion can become hemodynamically significant:

   • External compression the cardiac chambers

   • Restricted diastolic filling

   • Cardiac tamponade

4. Inflammation --> pericardial thickening --> constrictive pericarditis

Complications [eaa][ynn]

• Pericardial effusion

• Constrictive pericarditis

• Cardiac tamponade

• Recurrence (30%)

Epidemiology

Incidence per 100.000 [1oo][zth][mim][zn9]

Approach

• Blood test: troponin, complete blood count, CRP, basic metabolic panel, liver function tests, TSH, viral seromarkers, tuberculosis testing, tumor markers (CEA, CA-19)

• Blood gas

• Blood culture

• ECG

• Chest x-ray

• Echocardiography

• Pericardiocentesis

• Pericardial biopsy

• Cardiac catheterization

• CT/MRI

Diagnostic criteria: at least two of the following criteria [ysz]

• Characteristic pleuritic chest pain

• Pericardial rub on auscultation

• New typical ECG changes (widespread ST-elevation or PR-depression)

• Pericardial effusion on imaging

Treatment

1. Specific therapy appropriate to the underlying disorder is indicated [ysz][aro]

2. Non-pharmacological recommendation: restrict physical activity until resolution of symptoms and normalization of CRP

3. High risk case: Tuberculosis, fever > 38C, pericardial effusion, cardiac tamponade, lack of NSAIDs response, immunosuppression, trauma, anticoagulation therapy

   • Admission and search for etiology: Pericardiocentesis

   • Anti-tuberculosis antibiotics

   • Percardiotomy

4. Low-risk case --> Anti-inflammatory therapy

   • Aspirin 750-1000 mg every 8h for 1-2 weeks

   • NSAIDs: Ibuprofen 600 mg every 8h for 1-2 weeks

   • Colchicine: 0.5 mg x 1 (<70 kg) or 0.5 mg x 2 (>70 kg) for 3 months

   • Corticosteroids: 20-50mg x 1 (tapering 5-10 mg/day every I-2 weeks)

Differential diagnoses

Angina pectoris, Aortic dissection, Aortic stenosis, Cardiomyopathy, Cholecystitis, Costochondritis, Esophageal perforation, Esophageal rupture, Esophageal spasm, Esophagitis, Gastritis, Gastroesophageal reflux disease, Myocardial infarction, Myocarditis, Pleuritis, Pneumonia, Pneumothorax, Pulmonary embolism, Renal failure, Ruptured aortic aneurysm, Ulcer disease