History

The salient symptom of pericarditis (resulting from any etiology) is sharp, retrosternal chest pain that may radiate towards the shoulders and neck. Typically, the pain is relieved by sitting forward and exaggerated by lying supine. Deep inspiration, coughing and sneezing also sharply exaggerate the pain.
Depending upon the etiology, non-specific symptoms such as fever, chills and sweating may also be present.

Physical examination

The diagnostic sign of pericarditis on physical examination is friction rub. It is heard on auscultation as a superficial, scratching sound localized to a small area of the precordium, usually in systole. The sound is best heard when at expiration with the patient leaning forward. Tachycardia may also be present.

• Fever

  Fever and chest pain, which is sharp and varies with position and movement and occasionally may feel like a heart attack, are common symptoms. [merckmanuals.com]

  Tags: Chest Pain fever Pericarditis Sean M. Fox I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. [pedemmorsels.com]

• Fatigue

  Sometimes, non-specific symptoms such as irritability, loss of appetite, or fatigue will be all that the child is able to express. The symptoms of pericarditis may resemble other medical conditions or heart problems. [cincinnatichildrens.org]

  Clinical signs include fatigue, muscle wasting, and weight loss Applies To Concato's disease Pick's disease of heart (and liver) ICD-9-CM Volume 2 Index entries containing back-references to 423.2 : [icd9data.com]

  Fatigue occurs because the abnormal pericardium interferes with the heart's pumping action, so that the heart cannot pump enough blood to meet the body's needs. [msdmanuals.com]

  Hospital due to fatigue and chest discomfort. Laboratory findings showed that WBC count and C-reactive protein were increased. Echocardiographic finding was normal. The patient was admitted with a diagnosis of pericarditis. [ncbi.nlm.nih.gov]

• Dyspnea

  A 36-year-old pregnant woman was visiting the emergency department for dyspnea and flu-like syndrom that had been going on for a week. [ncbi.nlm.nih.gov]

  After treatment with diuretics, the peripheral edema improved significantly, but the patient still complained of severe dyspnea on exertion during the hospitalization. [casesjournal.biomedcentral.com]

  People with pericarditis may also develop dyspnea (shortness of breath) and fever. [heartdisease.about.com]

• Tachypnea

  […] cyclosporine, hydralazine, warfarin, heparin Radiation induced Aortic dissection Tetracyclines Postpericardiotomy syndrome: usually after CABG surgery Clinical features Chest pain, usually precordial or retrosternal Low grade intermittent fever Dyspnea / tachypnea [pathologyoutlines.com]

  Subsequently, the patient had spiking fevers, one of which was associated with tachypnea, severe dyspnea, and arterial desaturation. [revespcardiol.org]

  Common associated signs and symptoms include low-grade intermittent fever, dyspnea/tachypnea (a frequent complaint and may be severe, with myocarditis, pericarditis, and cardiac tamponade), cough, and dysphagia. [medscape.com]

  >10mmHg exaggeration of the normal respiratory variation in blood pressure), hypotension, tachycardia, increased venous pressure, hepatomegaly, edema, tachypnea, and fever. [cancertherapyadvisor.com]

• Painful Cough

  Sudden pericarditis: Stabbing pain on the left side of your chest Pain gets worse when you breathe deeply or lie down Low-grade fever Muscle pain Cough Feelings of weakness or fatigue Pericardial effusion: Trouble breathing A bluish skin color Constrictive [trihealth.adam.com]

  Chest pain, cough, and breathlessness are uncommon symptoms [10]. [intechopen.com]

  Endocarditis Fever and chills New or worsening heart murmur Blood in urine Spleen that is larger than normal Abdominal pain Chest pain Cough, with or without the presence of blood Loss of appetite and weight loss Muscle, joint, and back pain Night sweats [nhlbi.nih.gov]

• Orthopnea

  Pericardial effusion symptoms may include : Shortness of breath or difficulty breathing (dyspnea) Shortness of breath when lying down (orthopnea) Chest pain, usually behind the breastbone or on the left side of the chest Cough Painful breathing, especially [cardiachealth.org]

  There was no chest discomfort, orthopnea or paroxysmal nocturnal dyspnea. He did not have symptoms of cough, fever, foamy urine, or body weight loss. He had diabetes mellitus for years, which was well controlled with insulin. [casesjournal.biomedcentral.com]

  Cardiac tamponade which leads to: (1) Dyspnea (2) Agitation (3) Orthopnea (4) Cough d. Pericardial friction rub - occurs in less than 50% of patients. [atsu.edu]

  The symptoms of pericardial effusion include dyspnea, orthopnea, fatigue, weakness, and syncope. Signs Pericardial rub is the pathognomomic sign of pericarditis. It is nearly 100% specific, but not very sensitive. [bcmj.org]

  Prolonged elevation of pulmonary venous pressure results in dyspnea (particularly during exertion) and orthopnea. Fatigue may be severe. [merckmanuals.com]

• Pleuritic Pain

  Pericarditis that develops about 10 days to 2 months after a heart attack is usually accompanied by postmyocardial infarction syndrome (Dressler syndrome), which includes fever, pericardial effusion (extra fluid in the pericardial space), pleuritic pain [msdmanuals.com]

  Pericarditis that develops about 10 days to 2 months after a heart attack is usually accompanied by Dressler syndrome (postmyocardial infarction syndrome), which includes fever, pericardial effusion (extra fluid in the pericardial space), pleuritic pain [merckmanuals.com]

• Hiccup

  Image Credit: Joshya / Shutterstock Chronic Effusive Pericarditis It is difficult to exactly measure the span of CEP spread since the symptoms are not clear in most cases; however, some of the symptoms are chest pain, lightheadedness, hiccups, and shortness [news-medical.net]

  In cases where symptoms are present, they may include: chest pain light-headedness cough shortness of breath hiccups Possible causes of chronic effusive pericarditis include: infections, such as hepatitis or tuberculosis cancers that spread from other [hse.ie]

  Sometimes the patient may complain of dizziness, palpitations or syncope; 68% of patients refer cough, others voice hoarseness, anxiety and hiccups. Our patient had moderate effort dyspnea, and the moderate oppressive retrosternal pain. [scielo.org.mx]

• Odynophagia

  Two weeks later, he was readmitted with signs of pericarditis, a temperature of 38°C, fatigue, cough, and odynophagia. On echocardiography, no significant pericardial effusion was seen. [revespcardiol.org]

  Other mucosal surfaces may be involved, including the conjunctiva, [2] esophagus (causes odynophagia and/or dysphagia), [3] labia, vagina, cervix, vulva, [4] penis, urethra, nasal mucosa, and anus. [emedicine.medscape.com]

• Chest Pain

  For some people, the pain feels like a dull ache or pressure in the chest. The chest pain also may feel like pain from a heart attack. If you have chest pain, you should call 9–1–1 right away, as you may be having a heart attack. [web.archive.org]

  BACKGROUND: Pericarditis is an important diagnosis to consider, along with various other differential diagnoses, in a patient who presents with chest pain. [ncbi.nlm.nih.gov]

• Palpitations

  Other symptoms are weakness, palpitations, trouble breathing, and coughing. (Palpitations are feelings that your heart is skipping a beat, fluttering, or beating too hard or too fast.) The most common symptom of chronic pericarditis is chest pain. [web.archive.org]

  Because of this people with pericarditis may often feel isolated, causing them to experience other effects such as anxiety, palpitations and panic attacks. [bhf.org.uk]

  Symptoms of pericarditis include palpitations, a dry cough, and pain in the shoulder. In rare cases, pericarditis can permanently scar the pericardium. Pericarditis is an inflammation of the pericardium. [medicalnewstoday.com]

• Pericardial Friction Rub

  DISCUSSION: Characteristic clinical findings in pericarditis include pleuritic chest pain and pericardial friction rub on auscultation of the left lower sternal border. [ncbi.nlm.nih.gov]

  Signs and symptoms of pericarditis include: pericardial friction rub, fever, chest pain, pain while lying in the supine position, and ST segment elevation on an EKG. [youtube.com]

  The classic physical finding is a pericardial friction rub. A low-grade fever is often present. [bestpractice.bmj.com]

• Tachycardia

  Example 2 Acute Pericarditis: Sinus tachycardia Widespread concave STE and PR depression (I, II, III, aVF, V4-6). Reciprocal ST depression and PR elevation in V1 and aVR. [lifeinthefastlane.com]

  Her haemodynamic parameters worsened, including hypotension and tachycardia. Pericardiocentesis was performed in view of acute deterioration. [academic.oup.com]

  Electrical alternans, sinus tachycardia, and PR-segment depression are major signs in pericarditis. [dergipark.org.tr]

• Retrosternal Chest Pain

  Symptoms include sharp, severe retrosternal chest pain worse with inspiration and a supine position. The classic physical finding is a pericardial friction rub. A low-grade fever is often present. [bestpractice.bmj.com]

  We report a rare case of a mediastinal malignant granular cell tumor in a 41-year-old man presenting with dyspnea, retrosternal chest pain, and recurrent pericardial effusion under treatment with corticosteroids. [ncbi.nlm.nih.gov]

  Symptomology The prototypical symptom of acute pericarditis is retrosternal chest pain which may also refer to the back and shoulders. [pathwaymedicine.org]

  History The salient symptom of pericarditis (resulting from any etiology) is sharp, retrosternal chest pain that may radiate towards the shoulders and neck. Typically, the pain is relieved by sitting forward and exaggerated by lying supine. [symptoma.com]

• Hepatomegaly

  He had leg oedema, hepatomegaly, jugular venous distension, and bilateral pleural effusion on chest radiography. Laboratory data revealed elevated immunoglobulin G and G4 (IgG 2024 mg/dL, IgG4 177 mg/dL) and C-reactive protein (2.65 mg/dL) levels. [doi.org]

  However, there may be other more chronic signs also, such as: Pulmonary effusion – dyspnoea, cough, orthopnoea Reduced cardiac output – hypotension, fatigue, reflex tachycardia Pulmonary venous congestion – ascites, hepatomegaly, raised JVP Atrial dilation [almostadoctor.co.uk]

  >10mmHg exaggeration of the normal respiratory variation in blood pressure), hypotension, tachycardia, increased venous pressure, hepatomegaly, edema, tachypnea, and fever. [cancertherapyadvisor.com]

  […] effusion Low-grade intermittent fever, tachypnea, dyspnea, nonproductive cough Constrictive pericarditis [6][5] Symptoms of fluid overload (i.e., backward failure) Jugular vein distention, ↑ jugular venous pressure Kussmaul sign Hepatic vein congestion: hepatomegaly [amboss.com]

• Myalgia

  An early set of symptoms - a prodrome - of fever (usually <39°C), malaise and myalgia and/or arthralgia is common. The typical complaint is chest pain, that is most often pleuritic (exacerbated by inspiration). [escardio.org]

  Symptoms Exercise intolerance Fatigue Prodrome (if infectious) Fever Malaise Myalgias VI. [fpnotebook.com]

  Myocarditis may develop as a complication of an upper respiratory or gastrointestinal infection with general constitutional symptoms, particularly fever and skeletal myalgia, malaise, and anorexia. [heart.bmj.com]

  […] and 10 to 30% of patients will relapse after an initial response. 3 Less than 5% of the total population with acute pericarditis has multiple recurrences. 9 Clinical picture The clinical symptoms in most patients consist of viral prodrome with fever, myalgia [scielo.br]

• Night Sweats

  sweats, recent travel, autoimmune disease or sick contacts. [ncbi.nlm.nih.gov]

  Tuberculous pericarditis may present with constitutional symptoms, including fever, night sweats, anorexia, and weight loss. [radiopaedia.org]

  sweats, and weight loss are common Diagnosis Initial evaluation includes a clinical history and physical examination, ECG, echocardiography, chest radiography, lab studies 12 lead electrocardiogram shows diffuse, nonspecific, concave, ST segment elevation [pathologyoutlines.com]

  An evaluation for autoimmune and infectious disease should be carried out in patients with fever (temperature > 38°C; 100.4°F), recurrent pericarditis, recurrent large pericardial effusion or tamponade, or night sweats despite conventional medical therapy [mdedge.com]

• Agalactia

  Abstract BACKGROUND In the modern antibiotic era, Streptococcus agalactiae infection of the endocardium and pericardial space is a rare occurrence. [ncbi.nlm.nih.gov]

• Agitation

  The most common co-existing conditions in Pericarditis and stress are: Depression Pain Agitation Hypertension Hypotension Diabetes Schizophrenia Blood pressure Post-traumatic stress disorder Bipolar I disorder The most common medications used are: Seroquel [pericarditispain.info]

  Echocardiography may be used to guide the needle as agitated saline is injected through it. Agitated saline contains microbubbles, facilitating its identification by contrast during echocardiography. [merckmanuals.com]

  Cardiac tamponade which leads to: (1) Dyspnea (2) Agitation (3) Orthopnea (4) Cough d. Pericardial friction rub - occurs in less than 50% of patients. [atsu.edu]

  Echocardiography may be used to guide the needle as agitated saline is injected through it. Echocardiography is also increasingly used to identify the optimal puncture site and the needle trajectory. [msdmanuals.com]

Laboratory tests

• Complete blood count (CBC): Complete blood count may reveal an increase in the number of leukocytes.
• Erythrocyte sedimentation rate (ESR): Erythrocyte sedimentation rate is raised in pericarditis.
• C reactive protein: C reactive protein is an inflammatory marker and may be raised in pericarditis.
• Viral titers: Raised viral titers may be present when pericarditis has a viral etiology.
• Tuberculin skin test: This test is helpful in diagnosing pericarditis caused by Mycobacterium tuberculosis.
• Antinuclear antibody (ANA) and rheumatoid factor: The level of these factors may be tested if autoimmune etiology is suspected.

Electrocardiography

Electrocardiogram shows ST segment elevation with upward concavity [6]. These changes evolve through the following 4 stages [7].

• Stage I: In this stage, there is a diffuse elevation of ST segment with and depression of PR segment.
• Stage II: This stage is characterized by normalization of the ST and PR segments.
• Stage III: In stage III, there are widespread T wave inversions.
• Stage IV: In stage IV, there is normalization of T waves.

Imaging

• Chest X-rays: Chest X-ray is used to look for signs of pericardial effusion as well as any other underlying cardiac disease.
• Transthoracic echocardiography: This is used to detect pericardial effusion, cardiac tamponade or any cardiac disease.
• Computerized tomography (CT) and magnetic resonance imaging (MRI): CT and MRI are helpful in diagnosing the disease when other modalities are not conclusive.

Procedures

Pericardial fluid examination and pericardial biopsy: Examination of the pericardial fluid and biopsy of the pericardium can yield useful information regarding the etiology.

• Depressed PR Interval

  The axis is usually vertical with counter clockwise rotation, a short and depressed PR interval, prominent U waves, and sinus bradycardia. The ST segment becomes isoelectric with exercise or administration of isoprenaline. [heart.bmj.com]

• ST Elevation

  Pericarditis can cause localised ST elevation but there should be no reciprocal ST depression (except in AVR and V1). STEMI, like pericarditis, can also cause concave up ST elevation. Only STEMI causes convex up or horizontal ST elevation. [lifeinthefastlane.com]

  This can lead to ST elevation in all leads. Therefore, it is important to distinguish pericarditis from a myocardial infarction, which has more acute complaints and ST-elevations are limited to the infarct area. [en.ecgpedia.org]

• ST Elevation in All Leads

  In pericarditis four stages can be distinguished on the ECG: stage I: ST elevation in all leads. [en.ecgpedia.org]

  The characteristic ECG findings include upward concave ST elevation in all leads, diffuse PR depression, and the absence of reciprocal changes or T-wave inversion. [journals.lww.com]

• T Wave Inversion

  Upward convex ST-segment elevation May have T-wave inversion in leads with ST-segment elevation No PR-segment depression No Q waves View/Print Figure FIGURE 2. [aafp.org]

  […] lead aVR demonstrates ST segment depression this lead also may demonstrate PR segment elevation diffuse PR segment depression excluding the aforementioned (lead aVR) later, T wave inversions may develop In general, infection is the most common cause [radiopaedia.org]

  On hospital day 5, the ECG showed ST elevation in leads II, III, aVF, V3, and V4 and T wave inversion in V3-V6. Figure 2. The ECG on hospital day 9. Figure 3. In the ECG 90 days after presentation, the ST segment and T-wave inversion had normalized. [ekjm.org]

  wave changes, characteristic progression beginning with diffuse ST elevations, followed by a return to baseline, then T wave inversions PR depression indicates atrial injury Chest radiograph Frequently normal Cardiac enlargement if pericardial effusion [accessmedicine.mhmedical.com]

The goals of treatment in acute pericarditis are to reduce the pain and prevent the development of complications [8].

Non-steroidal anti-inflammatory drugs (NSAIDS) are the first line agents for the reduction of pain and inflammation in acute pericarditis [9]. Ibuprofen, aspirin and indomethacin are the NSAIDs commonly used. The duration of treatment is 1 to 2 weeks, however in case of recurrences, they are continued for up to 4 weeks. Since these drugs have a tendency to cause gastric bleeding with chronic use, they should be used in combination with misoprostol to prevent this adverse effect.

If the pain of pericarditis is not sufficiently reduced by the use of NSAIDs, corticosteroids such as prednisolone may also be used. A dose of 60 mg is given for 2 days. This dose is then tapered over a period of 2 weeks.

If steroid therapy is to be avoided, colchicine can be given for 3 months as an alternative adjunct to NSAIDs [10]. It is known to reduce the symptoms and prevent recurrences.

Pericarditis is mostly a benign, self-limiting disease with a very good prognosis. The signs and symptoms of uncomplicated pericarditis usually resolve by 1 to 2 weeks [4]. Recurrence occurs in up to 24% of the patients, usually within the first week after the initial episode.

Certain complications can prolong the duration of the disease and may even prove fatal. Cardiac tamponade, constrictive pericarditis and effusive-constrictive pericarditis are the troublesome complications of this disease [5].

Pericarditis can result from a wide range of infectious and non-infectious causes.

The common infectious causes include viruses (such as coxsackievirus, echovirus and adenovirus) and Mycobacterium tuberculosis [1] [2]. Other less common causes include gram positive and gram negative bacteria, fungi (such as Blastomyces dermatitidis, Candida sp. and Histoplasma capsulatum). Parasites such as Echinococcus may also cause pericarditis.

The most common non-infective cause of pericarditis is myocardial infarction in which pericarditis develops 1 to 4 days after any acute attack.

Pericarditis can also be caused by infiltration of the pericardium by malignant cells arising from lung carcinoma, breast carcinoma, leukemias or lymphomas. Mediastinal and thoracic radiation for the treatment of these malignancies can also cause pericarditis.

Pericarditis can also result from certain autoimmune causes such as connective tissue disorders, systemic lupus erythematosus, scleroderma and rheumatoid arthritis. Renal failure leading to uremia may also cause the development of pericarditis [3].

Certain drugs such as doxorubicin, isoniazid, dantrolene, rifampin and phenytoin may also cause the development of pericarditis. Other etiologies include chest trauma and surgical procedures.

There is not much epidemiological data available regarding pericarditis. However, surveys in various hospitals have revealed that pericarditis occurs in up to 5% of the people who present to the emergency departments with chest pain.

Pericarditis is the acute or chronic inflammation of the pericardium. There may be associated serous, purulent or fibrinous exudate depending upon the etiology.

Pericarditis results from a wide number of causes and therefore can not be prevented by specific guidelines. In general, good hygiene should be adopted, proper immunization should be done and the risk factors for myocardial infarction (such as smoking, unhealthy diet etc.) should be avoided.

Pericarditis is the inflammation of the pericardium – the fibroserous sac that surrounds the heart and the roots of the great vessels. It may occur due to infections, myocardial infarction, trauma, connective tissue disorders or malignant diseases. It is characterized by sharp retrosternal pain radiating to the neck and shoulders and typically exaggerating on deep breathing and coughing.

The prognosis of the patients suffering from pericarditis is very good. Drugs such as non-steroidal anti-inflammatory drugs, steroids and colchicine treat this condition and provide excellent relief from symptoms.

Pericarditis is the medical term to describe an inflammation of the fibrous sac that covers the heart. There are many causes of pericarditis but it usually occurs due to infection with viruses or as a complication of heart attack. The typical features of pericarditis include chest pain that is felt up to the level of the neck or shoulders. The pain increases in severity when the patient coughs or takes deep breaths. Pericarditis is usually not a dangerous condition and is managed easily by the use of painkilling medications.

1. Kawecka-Jaszcz K. [Pericarditis: classification, etiology, pathogenesis]. Folia medica Cracoviensia. 1991;32(1-2):15-22.
2. Purtskhvanidze Ch G, Georgadze AS, Givishvili UA. [Exudative pericarditis of tuberculous etiology]. Problemy tuberkuleza. 1986(11):63.
3. Frei D, Willimann P, Binswanger U. [Uremic pericarditis. Etiology and symptoms]. Deutsche medizinische Wochenschrift. Nov 23 1979;104(47):1660-1661.
4. Ilan Y, Oren R, Ben-Chetrit E. Acute pericarditis: etiology, treatment and prognosis. A study of 115 patients. Japanese heart journal. May 1991;32(3):315-321.
5. Habib G. [Acute pericarditis. Etiology, diagnosis, course, complications, treatment]. La Revue du praticien. Jan 1 1997;47(1):91-96.
6. Hannibal GB. ECG characteristics of acute pericarditis. AACN advanced critical care. Jul-Sep 2012;23(3):341-344.
7. Masek KP, Levis JT. ECG diagnosis: acute pericarditis. The Permanente journal. Fall 2013;17(4):e146.
8. Le Roux A. [Acute pericarditis: etiology, diagnosis, course, complications and treatment]. La Revue du praticien. Nov 15 1999;49(18):2049-2052.
9. Imazio M, Adler Y. Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis. Heart failure reviews. May 2013;18(3):355-360.
10. Cacoub PP. Colchicine for treatment of acute or recurrent pericarditis. Lancet. Jun 28 2014;383(9936):2193-2194.