Pericarditis

Background

• Inflammation or infection of the pericardial sac

Microbiology

• Idiopathic (most common)
• Infectious
  • Viral
    • Coxsackievirus A and B
    • Echovirus 8
    • Adenovirus
    • Others: Epstein-Barr virus, cytomegalovirus, influenza, varicella, rubella, HIV, hepatitis B, mumps, parvovirus B19, vaccinia virus (smallpox vaccine)
  • Mycobacterial: Mycobacterium tuberculosis
  • Bacterial
    • Staphylococcus aureus
    • Streptococcus pneumoniae
    • Haemophilus influenzae
    • Neisseria meningitidis
    • Others: Chlamydia psittaci, Chlamydia trachomatis, Legionella, Salmonella, Borrelia burgdorferi, Mycoplasma, Actinomyces, Nocardia, Tropheryma whipplei, Treponema, Rickettsia, Listeria
  • Fungal: Histoplasma (most common fungal cause), Aspergillus, Blastomyces, Coccidioides, Candida
  • Parasitic: Echinococcus, Entamoeba histolytica, Toxoplasma, Schistosoma species
• Non-infectious
  • Malignancy
    • Primary: rhabdomyosarcoma, teratoma, fibroma, lipoma, leiomyoma, angioma
    • Metastatic: lung, breast, Hodgkin lymphoma, leukemia, melanoma
  • Autoimmune disorders
  • Post-MI: either early or late (Dressler syndrome)
  • Metabolic: uremia, hypothyroidism
  • Radiation

Clinical Manifestations

• Positional chest pain, often several weeks following viral infection (most commonly Coxsackievirus)

Prognosis and Complications

Recurrent Pericarditis

• Pericarditis recurs in 15 to 30% of patients

Constrictive Pericarditis

• Scarring a loss of elasticity of the pericardium following pericarditis

Cardiac Tamponade

• Accumulation of pericardial effusion resulting in increased intrapericarial pressure causing heart failure

Differential Diagnosis

• Other causes of acute chest pain

Investigations

• Labs: lytes/creatinine (for NSAID safety), troponins
• Echocardiogram
• ECG, which evolves over weeks
  • Stage I: diffuse ST elevation with PR depression
  • Stage II: normalization of ST and PR segments
  • Stage III: diffuse deep T-wave inversions
  • Stage IV: normalization of the ECG
  • May show electrical alternans with large pericardial effusions

Diagnosis

• Based on 2 of 4 features:
  • Positional chest pain
  • Characteristic EKG abnormalities
  • Characteristic findings on echocardiography
  • Rub on auscultation

Management

• Mainstay of treatment is NSAIDs for 1-2 weeks, tapered over another 2-3 weeks
  • ASA 650mg po qid with pantoprazole
  • Indomethacin
• Adjunctive colchicine for 3 months
• If refractory or NSAID allergy: steroids with a slow taper
  • Increased recurrence rate