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Pericarditis

Pericarditis is the inflammation of the pericardium which can result from a wide range of infectious and non-infectious causes.


Presentation

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.

Dyspnea
  • 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]
  • 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]
  • A 65-year-old male patient presented with a fever, dyspnea, and right upper quadrant abdominal pain.[ncbi.nlm.nih.gov]
  • People with pericarditis may also develop dyspnea (shortness of breath) and fever.[heartdisease.about.com]
Tachypnea
  • […] pericardial effusion and may show the following on examination: narrow pulse pressure, pulsus paradoxus (i.e. 10mmHg exaggeration of the normal respiratory variation in blood pressure), hypotension, tachycardia, increased venous pressure, hepatomegaly, edema, tachypnea[clinicaladvisor.com]
  • While physical examination will concentrate on the heart examination, general assessment of the patient may find the presence of fever, a rapid heartbeat (tachycardia) or rapid breathing rate (tachypnea).[emedicinehealth.com]
  • Tachypnea and nonproductive cough may be present; fever, chills, and weakness are common. In 15 to 25% of patients with idiopathic pericarditis, symptoms recur intermittently for months or years (recurrent pericarditis).[merckmanuals.com]
Orthopnea
  • 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]
  • 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]
  • Prolonged elevation of pulmonary venous pressure results in dyspnea (particularly during exertion) and orthopnea. Fatigue may be severe.[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]
Painful Cough
  • Make sure you are familiar with the signs and symptoms of your condition, such as chest pain, cough, fever, and shortness of breath. Call your doctor with any new symptoms.[nhlbi.nih.gov]
Fever
  • 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]
  • Patients who have viral pericarditis present with fever and chest pain, and most have a friction rub. Viral pericarditis, unlike the other infectious disorders, often is accompanied by myocarditis.[pedsinreview.aappublications.org]
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]
  • 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]
  • It may also present with a dry cough , fever , fatigue and anxiety . Care must be taken to differentiate it from a myocardial infarction as the symptoms are similar.[house.wikia.com]
  • Chronic pericarditis is the persistent recurrence of acute pericarditis, and can lead to scarring of the pericardium, difficulty breathing, fatigue and fluid retention.[hopkinsmedicine.org]
Whipple Disease
  • disease Fungal Aspergillosis Blastomycosis Candida Coccidioidomycosis Histoplasmosis Other Parasitic Protozoal Noninfectious Acute idiopathic* Acute myocardial infarction* Neoplastic* Primary tumors Fibroma Lipoma Mesothelioma Sarcoma Metastatic tumors[aafp.org]
  • disease Familial Mediterranean fever Serum sickness Renal failure Richard Bright described uremic pericarditis in 1836.[emedicine.medscape.com]
Infectious Mononucleosis
  • Other viruses can be involved, examples include: Epstein-Barr virus that causes infectious mononucleosis , herpes simplex type 1 , measles , mumps , and human immunodeficiency virus ( HIV ).[emedicinehealth.com]
Hiccup
  • 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]
Increased Abdominal Girth
  • Review Topic QID: 104318 M2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M2.CV.115) A 65-year-old male with a past medical history of a 2-vessel coronary bypass surgery six months ago presents with increasing abdominal girth, peripheral[step2.medbullets.com]
Jaw Claudication
  • Common manifestations include constitutional symptoms, headache, jaw claudication, scalp tenderness, and vision loss.[ncbi.nlm.nih.gov]
Chest Pain
  • The most common symptom of chronic pericarditis is chest pain.[mayoclinic.org]
  • This can cause tachycardia (rapid pulse rate) and hypotension (reduced blood pressure) and chest pain. What are the symptoms of pericarditis? Typical symptoms associated with pericarditis include fever and chest pain.[childrenshospital.org]
  • Symptoms Symptoms include fever, sharp chest pain, difficulty breathing and fast heart rate. The chest pain characteristically gets worse on deep breathing and relieved when patient leans forward.[nhcs.com.sg]
Pericardial Friction Rub
  • 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]
  • The classic physical finding is a pericardial friction rub. A low-grade fever is often present.[bestpractice.bmj.com]
  • Acute pericarditis may appears with chest pain, fever, pericardial friction rub, and cardiac tamponade. Moreover, widespread ST segment changes occur due to involvement of the underlying epicardium.[ncbi.nlm.nih.gov]
  • There is often a pericardial friction rub with serial changes on the electrocardiogram. In dry pericarditis the friction rub is distinct, caused by deposits of fibrin, and may be heard through a stethoscope.[medical-dictionary.thefreedictionary.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]
  • Echocardiography revealed the large amount of pericardial effusion, and he was admitted to test the cause of pericardial effusion without high fever, tachycardia, and shock vital signs. On the third day, he suddenly presented vital shock.[ncbi.nlm.nih.gov]
  • This can cause tachycardia (rapid pulse rate) and hypotension (reduced blood pressure) and chest pain. What are the symptoms of pericarditis? Typical symptoms associated with pericarditis include fever and chest pain.[childrenshospital.org]
Palpitations
  • Depending on the cause of pericarditis, symptoms may also include: low fever heart palpitations shortness of breath weakness or fatigue nausea dry cough swelling of the legs or abdomen.[healthdirect.gov.au]
  • Symptoms may include: Chest pain that is often described as a sharp pain in the middle or left chest A low-grade fever Irregular heartbeat Shortness of breath Heart palpitations Fainting Children may not be able to describe that they have "chest pain"[stanfordchildrens.org]
  • The most common signs of pericarditis include chest pain, fever, weakness and tiredness, coughing, trouble breathing, pain when swallowing, and palpitations (irregular heartbeats).[cedars-sinai.edu]
Retrosternal Chest Pain
  • 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]
  • 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]
  • 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]
  • Patients with acute pericarditis commonly present with acute, sharp, retrosternal chest pain that is relieved by sitting or leaning forward. A pericardial friction rub is found in up to 85% of patients.[aafp.org]
Hepatomegaly
  • 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]
  • […] significant pericardial effusion and may show the following on examination: narrow pulse pressure, pulsus paradoxus (i.e. 10mmHg exaggeration of the normal respiratory variation in blood pressure), hypotension, tachycardia, increased venous pressure, hepatomegaly[clinicaladvisor.com]
  • Physical examination revealed generalized pitting edema with elevated jugular venous pressure, positive Kussmaul's sign, and hepatomegaly.[casesjournal.biomedcentral.com]
  • Symptoms and signs of peripheral venous congestion (eg, peripheral edema, neck vein distention, hepatomegaly) may appear with an early diastolic sound (pericardial knock), often best heard during inspiration.[merckmanuals.com]
  • Pulsatile hepatomegaly in constrictive pericarditis . Br. Heart J. 52 , 465–467 (1984). 103. Beck, W. , Schrire, V. & Vogelpoel, L.[nature.com]
Myalgia
  • Symptoms Exercise intolerance Fatigue Prodrome (if infectious) Fever Malaise Myalgias VI.[fpnotebook.com]
  • Common symptoms include fever, migratory myalgia, rash, and serositis. In an international registry of 138 patients with TRAPS, 7% had pericarditis and 25% had chest pain (67) .[onlinejacc.org]
Night Sweats
  • sweats, recent travel, autoimmune disease or sick contacts.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • Night sweats c. Weight loss d. Fatigue e. Progressive circulatory failure due to: (1) Slowly progressing dyspnea (2) Ascites (3) Edema In general all types of pericarditis may result in: a.[atsu.edu]
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]

Workup

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

Procedures

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

ST Elevation
  • 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]
  • Diagnostic signs include diffuse electrocardiographic ST elevations and at least a small pericardial effusion on echocardiography; blood tests generally suggest systemic inflammation. Treatment is directed at any underlying systemic disorder.[bestpractice.bmj.com]
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]
T Wave Inversion
  • inversion in leads with ST-segment elevation PR-segment depression Q waves during evolution ST-segment elevation in anatomically contiguous leads, with possible reciprocal ST-segment depression Upward convex ST-segment elevation T-wave inversion in leads[aafp.org]
  • Stage III: In stage III, there are widespread T wave inversions. Stage IV: In stage IV, there is normalization of T waves.[symptoma.com]
  • There may also be PR interval depression – and if both of these are present it is pretty much diagnostic for pericarditis Later there may also be T wave inversion – especially if myocarditis is also present.[almostadoctor.co.uk]
  • EKG changes in acute pericarditis can progress over four stages: Stage 1: diffuse ST elevations with or without PR depressions, initially; Stage 2: normalization of ST and PR segments, typically after several days; Stage 3: diffuse T-wave inversions;[the-hospitalist.org]
  • Classic changes include widespread concave upward ST-segment elevation and PR-segment depression without T-wave inversions.[aafp.org]

Treatment

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.

Prognosis

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].

Etiology

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.

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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

Prevention

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.

Summary

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.

Patient Information

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.

References

Article

  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.

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Last updated: 2017-08-09 17:33