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  • Pericarditis Authors: Doctor Sabiha Gati BSc (Hons), MBBS and Doctor Sanjay Sharma BSc (Hons), MBChB, MRCP (UK), MD1Creation Date: March 2005

    Scientific Editor: Professor William McKenna 1 University Hospital Lewisham, Lewisham High Street, London SE13 6LH. ssharma21@hotmail.com

    Abstract Keywords Background Definition and Classification Frequency ACUTE PERICARDITIS Clinical manifestation Other investigations Management Complications PERICARDIAL EFFUSION CARDIAC TAMPONADE Clinical Manifestations Investigations Management CONSTRICTIVE PERICARDITIS Clinical manifestations Investigations Management References Abstract Pericarditis is an inflammatory disorder of the serous pericardium resulting from a primary insult to the heart or is secondary to a systemic disorder. Of the many causes, the most frequently encountered include acute idiopathic pericarditis and viral infections. The condition is classically diagnosed by the presence of chest pain, presence of a pericardial friction rub and characteristic changes on ECG. Extensive investigations to elicit a cause are not necessary as they are of low diagnostic yield. Because of its frequently self-limiting nature, non-steroidal anti-inflammatory drugs are normally used as the first line treatment with the aim of dampening the inflammatory process and expediting recovery. Specific therapy should be initiated for an underlying disorder perpetuating pericarditis. Complications of pericarditis include pericardial effusions and subsequent tamponade and long term constrictive pericarditis. Further laboratory evaluation, echocardiography and pericardiocentesis should be considered for individuals likely to have these complications.

    Keywords Pericarditis, pericardial effusion, pericardial constriction

    Background The heart is surrounded by a protective pericardium made up of two layers, a serous and a fibrous component. The serous component is further divided into an inner, visceral and outer, parietal layer. A potential space, the pericardial cavity exists between

    the two layers of the serous pericardium that normally contains 15 to 50 mls of plasma fluid (1).

    Definition and Classification Pericarditis is an inflammatory disorder of the serous pericardium which may result from either a primary insult directly to the heart or be secondary to a large number of systemic disorders (Table 1). In most

    Gati S., Sharma S. Pericarditis. Orphanet Encyclopedia, March 2005. http://www.orpha.net/data/patho/GB/uk-Pericarditis.pdf

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  • instances the disorder is self-limiting but may be complicated by pericardial effusion or constriction.

    Table 1: Diseases affecting the pericardium. Adapted from (1). Trauma Myocardial Infarction

    Radiotherapy Aortic dissection Blunt or penetrating injury

    Infection Bacterial Tuberculosis, Streptococcus, Staphylococcus, Pneumococcus, Haemophilus, Legionella, Salmonella, Lyme disease, Neisseria meningitides & Gonorrhoea, Chlamydia psittaci & Trachomotis Viral HIV, Coxsackie virus A&B, echovirus, EBV, mumps, hepatitis B, influenza, varicella Fungal Histoplasmosis, aspergillosis, nocardia, candida, coccidiomycosis Parasitic Echinococcus, amebiasis, toxoplasmosis

    Neoplasm Primary or secondary Drugs Hydralazine, Procainamide, Cytotoxics,

    Phenytoin, Penicillin, Anticoagulants Endocrine Hypothyroidism Metabolic Uraemia, Amyloidosis Inflammatory Dresslers syndrome, Postcardiotomy Connective Tissue disorders

    RA, SLE, SS, PAN, Churg-strass, GCA, sarcoidosis, IBD, wegeners granulomatosis

    Acute Idiopathic

    HIV= Human immunodeficiency virus, EBV= Ebstein bar virus, RA= Rheumatoid arthritis, SLE= Systemic lupus erythematosus, SS= Systemic sclerosis, PAN= Polyarteritis nodosa, GCA= giant cell arteritis, IBD= inflammatory bowel disease.

    Frequency Epidemiological data on the incidence of pericarditis are scarce, possibly because the condition can be difficult to identify, and of its self-limiting nature. The frequency of pericarditis can vary in numerous disorders (Table 2). Mortality may vary according to the aetiology, being low with viral/idiopathic pericarditis and very high with purulent pericarditis (2).

    Table 2: Frequency of the disorder under different causes of pericarditis. Adapted from (14) Cause Accountable cases Infection Bacterial 1-8% Tuberculosis 4% Viral 1-10% Autoimmune Rheumatoid arthritis 11-50% Systemic lupus erythematosus

    25% (after autopsy 62%)

    Systemic sclerosis 5-10%(after autopsy 70%)Chronic Renal failure 12% Hypothyroidism 4% Myocardial infarction 7-23% Dresslers syndrome 4% Postcardiotomy 10-40% Neoplasm 5-17%

    ACUTE PERICARDITIS Aetiology

    The cause of pericardial disease in many cases is unknown, particularly in young adults. Studies suggest a viral aetiology (coxsackie B) in most cases. Since the disease is usually self-limiting the cause is not investigated as there is a considerable time lag before the results of the viral titre are available and the initiation of treatment. The diagnosis can be made from the clinical presentation and does not require positive virology titres. Individuals may present with chest pain and flu-like symptoms. Although the condition is self-limiting, recurrence over the following 6 to 12 months may occur with an immunological basis.

    Viral pericarditis Coxsackie virus A & B, echovirus, adenovirus and HIV are the most commonly implicated viral causes of acute pericarditis. Seasonal epidemics are known to occur with influenza and coxsackie B. Viral pericarditis is typically self-limiting, lasting 1-3 weeks and is treated symptomatically. HIV can facilitate infection of the pericardium by non-virulent organisms or can directly infect the pericardium. HIV typically causes small asymptomatic pericardial effusions.

    Bacterial pericarditis The most common bacterial causes are Staphylococcus aureus, Streptococcus pneumonie, Haemophilus influenzae and Mycobacterium tuberculosis. The spread is either haematogenous or directly from the lungs or pleura. Less common bacterial infections may be seen in the immunocompromised and in those with altered bacterial flora from extensive prolonged antibiotic therapy.

    Tuberculosis pericarditis Tuberculous pericarditis is rare in the western world, however, it is still an important cause of pericardial disease in the third world. Both parietal and visceral layers of pericardium are infected and the myocardium is involved in most cases. Tuberculous pericarditis can present in the form of acute pericarditis, pericardial effusion or with constrictive pericarditis. Treatment is with antituberculous drugs. Steroids hasten recovery in the first 11 weeks but should be avoided in tuberculous pericarditis secondary to HIV syndrome.

    Fungal infection Fungal pericarditis is rare and is usually manifest in immunocompromised patients. Histoplasma is the most common fungal organism in the immuno-sufficient individuals and is known to cause constriction and calcification. Infections with actinomycosis (Actinomyces), coccidiodomycosis (Coccidioides), Candida and Aspergillus have also been reported.

    Malignancy Neoplastic disorders affecting the pericardium include rare primary tumours such as mesotheliomas or myosarcomas or, more commonly are secondary to metastases from the lung, breast, gastro-intestinal tract and haematological malignancies. Malignancy is frequently associated with moderate to large effusions (2,3), and may lead to tamponade. Patients with

    Gati S., Sharma S. Pericarditis. Orphanet Encyclopedia, March 2005. http://www.orpha.net/data/patho/GB/uk-Pericarditis.pdf

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  • neoplastic pericardial effusions may also present with supraventricular arrhythmias, or features of constrictive pericarditis. Generally, malignant pericardial effusions require drainage. The diagnosis of neoplastic pericardial effusion is based on cytological examination of pericardial fluid or direct histological tests on the pericardium (4,5). Recurrent effusions are treated by surgical fashioning of a continuum window into the pleural cavity.

    Hypothyroidism Hypothyroidism causes silent pericardial effusion that is rarely of haemodynamic significance. Low voltage complexes are seen on the ECG. Thyroxine replacement alone is sufficient to resolve the pericardial effusion.

    Myocardial infarction Acute pericarditis and/or effusion, are manifested in approximately 15% of patients following an myocardial infarct (MI) (5,6,7,8). The overall incidence of MI induced pericardial disease is reduced by 50% with thrombolytic therapy (7). Infarct size and early initiation of thrombolytic therapy determines the incidence and extent of pericardial involvement (7). The acute insult to the pericardium presents in the first 24 to 72 hours, and gives rise to a friction rub, dull retrosternal chest pain varying with posture and respiration and pericarditis, widespread ST elevation is labile. Patients are also more prone to supraventricular arrhythmia. An acute effusion may develop secondary to the inflammatory process related with the infarct but is usually silent.

    Dresslers syndrome Dresslers syndrome is seen in 3 to 4% of patients and occurs 2 to 4 weeks following a myocardial infarction. Also known as postcardiac injury syndrome, it is immunologically mediated and presents with a self-limiting febrile illness, pleural or pericardial pain and a pneumonitis. Patients with successful reperfusion after treatment with thrombolysis following MI are less likely to develop Dresslers syndrome (9).

    Metabolic cause of pericarditis Patients with untreated severe chronic renal failure are prone to uraemic pericarditis. Uraemic pericarditis is often

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