Pericarditis

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

Pericarditis10

Pericarditis10, CC BY-SA 3.0

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.

Respiratoric

Dyspnea

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]
The patient is told to report symptoms of recurrence, including fever, chest pain, and dyspnea.[medical-dictionary.thefreedictionary.com]
Other nonspecific symptoms that can be associated with pericarditis include vomiting, cough, dyspnea, abdominal pain and fever.[clinicaladvisor.com]
Bacterial Fungal Metabolic (ex, uremia, myxedema) Rheumatic Disease (ex, Lupus, Rheumatic Fever ) ( 30%) [ Roodpeyma, 2000 ] Neoplastic Disease ( 10%) [ Roodpeyma, 2000 ] Medication Adverse Reaction (ex, hydralazine, isoniazid) Trauma “Classic Triad” fever, dyspnea[pedemmorsels.com]

Tachypnea

Most children presented with chest pain, fever, and tachypnea, but cardiac tamponade was not seen in […] Durani Y1, Giordano K, Goudie BW. Myocarditis and pericarditis in children. Pediatr Clin North Am. 2010 Dec;57(6):1281-303. PMID: 21111118 .[pedemmorsels.com]
[…] 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]

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]
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]

Sneezing

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.[symptoma.com]

Entire body system

Fever

, 2000 ] Medication Adverse Reaction (ex, hydralazine, isoniazid) Trauma “Classic Triad” fever, dyspnea, and chest pain Of course, that sounds like pneumonia also. 96% of acute pericarditis present with Chest Pain [ Ratnapalan, 2011 ] Often described[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]
The inflammation, pain, dehydration and fatigue due to pericarditis and stress increases the patient’s overall stress level, which worsens the symptoms of diabetes.[pericarditispain.info]
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]

Gastrointestinal

Hiccup

Other symptoms may include a mild fever, weakness , feeling very tired, coughing , hiccups , and muscle aches. Pericarditis usually isn't dangerous. But your chest pain could be caused by something more serious, like a heart attack .[webmd.com]
Other symptoms may include a mild fever, weakness, feeling very tired, coughing, hiccups, and muscle aches. Pericarditis usually isn't dangerous. But your chest pain could be caused by something more serious, like a heart attack .[cigna.com]
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 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]

Cardiovascular

Chest Pain

The most common symptom of chronic pericarditis is chest pain.[mayoclinic.org]
pain Of course, that sounds like pneumonia also. 96% of acute pericarditis present with Chest Pain [ Ratnapalan, 2011 ] Often described as sharp, but can be dull.[pedemmorsels.com]
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]

Pericardial Friction Rub

The classic physical finding is a pericardial friction rub. A low-grade fever is often present.[bestpractice.bmj.com]
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]
There may be an associated pericardial friction rub or evidence of a pericardial effusion . Widespread ST segment changes occur due to involvement of the underlying epicardium (i.e. myopericarditis).[lifeinthefastlane.com]

Palpitations

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

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]
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]
Tachycardia may also be present. 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.[symptoma.com]

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]
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]

Liver, Gall & Pancreas

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]
Pulsatile hepatomegaly in constrictive pericarditis . Br. Heart J. 52 , 465–467 (1984). 103. Beck, W. , Schrire, V. & Vogelpoel, L.[nature.com]

Musculoskeletal

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]

Skin

Night Sweats

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]
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]

Neurologic

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]
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]

Altered Mental Status

mental status due to hypoperfusion of body organs by a heart that can not pump out blood effectively.[en.wikipedia.org]

Tingling

Retrieved 28 September 2016 . a b c d e f g h i j k l m n o p Tingle, LE; Molina, D; Calvert, CW (15 November 2007). "Acute pericarditis". American Family Physician . 76 (10): 1509–14. PMID 18052017 . a b "What Causes Pericarditis?" . NHLBI .[en.wikipedia.org]

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

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.

QT, RR, ST Intervals

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]
The most common pattern is ST elevation in leads, V5 and V6 (70%); more extensive involvement is indicated by additional ST elevation in leads , aVL, aVF and V 3-4.[rcemlearning.co.uk]

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

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]
Classic changes include widespread concave upward ST-segment elevation and PR-segment depression without T-wave inversions.[aafp.org]
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]

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

Kawecka-Jaszcz K. [Pericarditis: classification, etiology, pathogenesis]. Folia medica Cracoviensia. 1991;32(1-2):15-22.
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Masek KP, Levis JT. ECG diagnosis: acute pericarditis. The Permanente journal. Fall 2013;17(4):e146.
Le Roux A. [Acute pericarditis: etiology, diagnosis, course, complications and treatment]. La Revue du praticien. Nov 15 1999;49(18):2049-2052.
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Cacoub PP. Colchicine for treatment of acute or recurrent pericarditis. Lancet. Jun 28 2014;383(9936):2193-2194.

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