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Pericarditis

Pericarditis

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Pericarditis is an inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...

 of the pericardium
Pericardium
The pericardium is a double-walled sac that contains the heart and the roots of the great vessels.-Layers:...

 (the fibrous sac surrounding the heart
Heart
The heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...

). A characteristic chest pain
Chest pain
Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.-Differential...

 is often present.

The causes of pericarditis are varied, including viral infections of the pericardium, idiopathic
Idiopathic
Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek ἴδιος, idios + πάθος, pathos , it means approximately "a disease of its own kind". It is technically a term from nosology, the classification of disease...

 causes, uremic pericarditis
Uremic pericarditis
-Presentation:Fibrinous pericarditis is an exudative inflammation. The pericardium is infiltrated by the fibrinous exudate. This consists of fibrin strands and leukocytes. Fibrin describes an amorphous, eosinophilic network. Leukocytes are found within the fibrin deposits and intrapericardic....

, bacterial infections of the precardium (for i.e. Mycobacterium tuberculosis
Mycobacterium tuberculosis
Mycobacterium tuberculosis is a pathogenic bacterial species in the genus Mycobacterium and the causative agent of most cases of tuberculosis . First discovered in 1882 by Robert Koch, M...

), post-infarct pericarditis (pericarditis due to heart attack), or Dressler
Dressler's syndrome
Dressler's syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium...

's pericarditis.

Classification


Pericarditis can be classified according to the composition of the inflammatory exudate
Exudate
An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation. It can apply to plants as well as animals. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as sap or blood...

 or in other words the composition of the fluid that accumulates around the heart.

Types include:
  • serous
  • purulent
  • fibrinous
    Uremic pericarditis
    -Presentation:Fibrinous pericarditis is an exudative inflammation. The pericardium is infiltrated by the fibrinous exudate. This consists of fibrin strands and leukocytes. Fibrin describes an amorphous, eosinophilic network. Leukocytes are found within the fibrin deposits and intrapericardic....

  • caseous
  • hemorrhagic
  • Post infarction

Acute vs. chronic


Depending on the time of presentation and duration, pericarditis is divided into "acute" and "chronic" forms. Acute pericarditis
Acute pericarditis
Acute pericarditis is a type of pericarditis usually lasting 1.5 µg/L. Coronary angiography in those patients should indicated normal vascular perfusion. The elevation of these biomarkers are typically transient and should return to normal within a week. Persistence may indicated...

 is more common than chronic pericarditis, and can occur as a complication of infections, immunologic conditions, or even as a result of a heart attack (myocardial infarction). Chronic pericarditis however is less common, a form of which is constrictive pericarditis
Constrictive pericarditis
In many cases, constrictive pericarditis is a late sequela, in other words a condition that is the consequence of a previous disease, of an inflammatory condition of the pericardium...

. The following is the clinical classification of acute vs. chronic:
  • Clinically: Acute (<6 weeks), Subacute (6 weeks to 6 months) and Chronic (>6 months)

Signs and symptoms


Substernal or left precordial pleuritic chest pain
Chest pain
Chest pain may be a symptom of a number of serious conditions and is generally considered a medical emergency. Even though it may be determined that the pain is non-cardiac in origin, this is often a diagnosis of exclusion made after ruling out more serious causes of the pain.-Differential...

 with radiation to the trapezius ridge (the bottom portion of scapula
Scapula
In anatomy, the scapula , omo, or shoulder blade, is the bone that connects the humerus with the clavicle ....

 on the back), which is relieved by sitting up and bending forward and worsened by lying down (recumbent or supine
Supine
In grammar a supine is a form of verbal noun used in some languages.-In Latin:In Latin there are two supines, I and II . They are originally the accusative and dative or ablative forms of a verbal noun in the fourth declension, respectively. The first supine ends in -um. It has two uses. The first...

 position) or inspiration (taking a breath in), is the characteristic pain of pericarditis. The pain may resemble the pain of angina pectoris or heart attack, but differs in that pain changes with body position, as opposed to heart attack pain that is pressure-like, and constant with radiation to the left arm and/or the jaw. Other symptoms of pericarditis may include dry cough
Cough
A cough is a sudden and often repetitively occurring reflex which helps to clear the large breathing passages from secretions, irritants, foreign particles and microbes...

, fever
Fever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...

, fatigue, and anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...

. Due to similarity to myocardial infarction (heart attack) pain, pericarditis can be misdiagnosed as an acute myocardial infarction
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...

 (a heart attack) solely based on the clinical data and so extreme suspicion on the part of the diagnostician is required. Ironically an acute myocardial infarction
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...

 (heart attack) can also cause pericarditis, but often the presenting symptoms vary enough to warrant a diagnosis. The following table organises the clinical presentation of pericarditis:
Characteristic/Parameter Pericarditis Myocardial infarction
Pain description Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain Crushing, pressure-like, heavy pain. Described as "elephant on the chest."
Radiation Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation. Pain radiates to the jaw, or the left or arm, or does not radiate.
Exertion Does not change the pain Can increase the pain
Position Pain is worse supine
Supine
In grammar a supine is a form of verbal noun used in some languages.-In Latin:In Latin there are two supines, I and II . They are originally the accusative and dative or ablative forms of a verbal noun in the fourth declension, respectively. The first supine ends in -um. It has two uses. The first...

 or upon inspiration (breathing in)
Not positional
Onset/duration Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours before the patient decides to come to the ER

Physical examinations


The classic sign
Medical sign
A medical sign is an objective indication of some medical fact or characteristic that may be detected by a physician during a physical examination of a patient....

 of pericarditis is a friction rub auscultated on the cardiovascular examination usually on the lower left sternal border. Other physical signs include a patient in distress, positional chest pain, diaphoresis (excessive sweating), and possibility of heart failure in form of precardial tamponade
Tamponade
Tamponade is the closure or blockage as if by a tampon especially to stop bleeding.Tamponade is a useful method of stopping a hemorrhage...

 causing pulsus paradoxus
Pulsus paradoxus
In medicine, a pulsus paradoxus , also paradoxic pulse or paradoxical pulse, is defined as an exaggeration of the normal variation during the inspiratory phase of respiration, in which the blood pressure declines as one inhales and increases as one exhales...

, and the Beck's triad of hypotension (due to decreased cardiac output
Cardiac output
Cardiac output is the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute. CO may be measured in many ways, for example dm3/min...

), distant (muffled) heart sounds, and JVD (jugular vein distention).

Acute complications


Pericarditis can progress to pericardial effusion and eventually cardiac tamponade
Cardiac tamponade
Cardiac tamponade, also known as pericardial tamponade, is an emergency condition in which fluid accumulates in the pericardium ....

. This can be seen in patients who are experiencing the classic signs of pericarditis but then show signs of relief, and progress to show signs of cardiac tamponade which include decreased alertness and lethargy, pulsus paradoxus
Pulsus paradoxus
In medicine, a pulsus paradoxus , also paradoxic pulse or paradoxical pulse, is defined as an exaggeration of the normal variation during the inspiratory phase of respiration, in which the blood pressure declines as one inhales and increases as one exhales...

 (decrease of at least 10 mmHg of the systolic blood pressure upon inspiration
Inhalation
Inhalation is the movement of air from the external environment, through the air ways, and into the alveoli....

), hypotension (due to decreased cardiac index
Cardiac index
Cardiac index is a vasodynamic parameter that relates the cardiac output to body surface area , thus relating heart performance to the size of the individual...

), JVD (jugular vein distention from right sided heart failure and fluid overload), distant heart sounds on auscultation, and equilibration of all the diastolic blood pressures on cardiac catheterization due to the constriction of the pericardium by the fluid.

In such cases of cardiac tamponade, EKG or Holter monitor
Holter monitor
In medicine, a Holter monitor is a portable device for continuously monitoring various electrical activity of the cardiovascular system for at least 24 hours...

 will then depict electrical alterans
Electrical alternans
Electrical alternans is an electrocardiographic phenomenon of alternation of QRS complex amplitude or axis between beats and a possible wandering base-line...

 indicating wobbling of the heart in the fluid filled pericardium, and the capillary refill
Capillary refill
Capillary refill is the rate at which blood refills empty capillaries. It can be measured by holding a hand higher than heart-level , pressing the soft pad of a finger or toe until it turns white, and taking note of the time needed for the color to return once pressure is released. Normal refill...

 might decrease, as well as severe vascular collapse and altered mental status due to hypoperfusion of body organs by a heart that can not pump out blood effectively.

The diagnostic test for cardiac tamponade, is trans-esophageal echocardiography
Transesophageal echocardiogram
A transesophageal echocardiogram, or TEE , is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus...

 (TEE) although trans-thoracic echocardiography
Transthoracic echocardiogram
A standard echocardiogram is also known as a transthoracic echocardiogram , or cardiac ultrasound. In this case, the echocardiography transducer is placed on the chest wall of the subject, and images are taken through the chest wall. This is a non-invasive, highly accurate and quick assessment...

 (TTE) can also be utilized in cases where there is a high suspicion of aortic dissection
Aortic dissection
Aortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart. The dissection typically extends anterograde, but can extend retrograde from the site of the intimal tear. Aortic dissection is a medical...

 and high blood pressure, or in patients where esophageal probing is not feasible. Chest X-ray
Chest X-ray
In medicine, a chest radiograph, commonly called a chest X-ray , is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures...

 can depict a "water bottle" appearance of the heart in tamponade, although chest X-ray is not specific enough neither is it accurate enough in the acute setting. Of note is the fact that chest X-ray can be entirely normal in acute pericardial effusion/tamponade, so should not be relied upon as the sole diagnostic tool.

Infectious


Pericarditis may be caused by viral
Virus
A virus is a small infectious agent that can replicate only inside the living cells of organisms. Viruses infect all types of organisms, from animals and plants to bacteria and archaea...

, bacteria
Bacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...

l, or fungal
Fungus
A fungus is a member of a large group of eukaryotic organisms that includes microorganisms such as yeasts and molds , as well as the more familiar mushrooms. These organisms are classified as a kingdom, Fungi, which is separate from plants, animals, and bacteria...

 infection. The most common viral pathogen has traditionally been considered to be coxsackievirus
Coxsackievirus
Coxsackievirus is a virus that belongs to a family of non enveloped linear positive-sense ssRNA viruses, Picornaviridae and the genus Enterovirus, which also includes poliovirus and echovirus. Enteroviruses are among the most common and important human pathogens and ordinarily its members are...

 based on studies in children from the 1960s, but recent data suggest that adults are most commonly affected with cytomegalovirus
Cytomegalovirus
Cytomegalovirus is a viral genus of the viral group known as Herpesviridae or herpesviruses. It is typically abbreviated as CMV: The species that infects humans is commonly known as human CMV or human herpesvirus-5 , and is the most studied of all cytomegaloviruses...

, herpesvirus, and HIV
HIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...

. Pneumococcus or tuberculous pericarditis
Tuberculous pericarditis
Tuberculous pericarditis is a form of pericarditis.Pericarditis caused by tuberculosis is difficult to diagnose, because definitive diagnosis requires culturing Mycobacterium tuberculosis from aspirated pericardial fluid or pericardial biopsy, which requires high technical skill and is often not...

 are the most common bacterial forms. Anaerobic bacteria can also be rare cause. Fungal pericarditis is usually due to histoplasmosis
Histoplasmosis
Histoplasmosis is a disease caused by the fungus Histoplasma capsulatum. Symptoms of this infection vary greatly, but the disease primarily affects the lungs...

, or in immunocompromised hosts Aspergillus
Aspergillus
Aspergillus is a genus consisting of several hundred mold species found in various climates worldwide. Aspergillus was first catalogued in 1729 by the Italian priest and biologist Pier Antonio Micheli...

, Candida
Candida (genus)
Candida is a genus of yeasts. Many species are harmless commensals or endosymbionts of animal hosts including humans, but other species, or harmless species in the wrong location, can cause disease. Candida albicans can cause infections in humans and other animals, especially in immunocompromised...

, and Coccidioides
Coccidioides
Coccidioides is a genus of dimorphic ascomycete, cause of Coccidioidomycosis, also known as San Joaquin Valley Fever, an infectious fungal disease confined to the western hemisphere and endemic in American deserts...

. The most common worldwide cause of pericarditis is infectious pericarditis with Tuberculosis.

Other

  • Idiopathic
    Idiopathic
    Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek ἴδιος, idios + πάθος, pathos , it means approximately "a disease of its own kind". It is technically a term from nosology, the classification of disease...

    : No identifiable etiology found after routine testing.
  • Immunologic
    Immune mediated inflammatory diseases
    An immune-mediated inflammatory disease is any of a group of conditions or diseases that lack a definitive etiology, but which are characterized by common inflammatory pathways leading to inflammation, and which may result from, or be triggered by, a dysregulation of the normal immune response...

     conditions including systemic lupus erythematosus
    Systemic lupus erythematosus
    Systemic lupus erythematosus , often abbreviated to SLE or lupus, is a systemic autoimmune disease that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage...

     (more common among women) or rheumatic fever
    Rheumatic fever
    Rheumatic fever is an inflammatory disease that occurs following a Streptococcus pyogenes infection, such as strep throat or scarlet fever. Believed to be caused by antibody cross-reactivity that can involve the heart, joints, skin, and brain, the illness typically develops two to three weeks after...

  • Myocardial Infarction
    Myocardial infarction
    Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...

     (Dressler's syndrome
    Dressler's syndrome
    Dressler's syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium...

    )
  • Trauma
    Physical trauma
    Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

     to the heart, e.g. puncture, resulting in infection or inflammation
  • Uremia
    Uremia
    Uremia or uraemia is a term used to loosely describe the illness accompanying kidney failure , in particular the nitrogenous waste products associated with the failure of this organ....

     (uremic pericarditis
    Uremic pericarditis
    -Presentation:Fibrinous pericarditis is an exudative inflammation. The pericardium is infiltrated by the fibrinous exudate. This consists of fibrin strands and leukocytes. Fibrin describes an amorphous, eosinophilic network. Leukocytes are found within the fibrin deposits and intrapericardic....

    )
  • Malignancy (as a paraneoplastic phenomenon)
  • Side effect
    Adverse drug reaction
    An adverse drug reaction is an expression that describes harm associated with the use of given medications at a normal dosage. ADRs may occur following a single dose or prolonged administration of a drug or result from the combination of two or more drugs...

     of some medications, e.g. isoniazid
    Isoniazid
    Isoniazid , also known as isonicotinylhydrazine , is an organic compound that is the first-line antituberculosis medication in prevention and treatment. It was first discovered in 1912, and later in 1951 it was found to be effective against tuberculosis by inhibiting its mycolic acid...

    , cyclosporine, hydralazine
    Hydralazine
    Hydralazine is a direct-acting smooth muscle relaxant used to treat hypertension by acting as a vasodilator primarily in arteries and arterioles...

    , warfarin
    Warfarin
    Warfarin is an anticoagulant. It is most likely to be the drug popularly referred to as a "blood thinner," yet this is a misnomer, since it does not affect the thickness or viscosity of blood...

    , and heparin
    Heparin
    Heparin , also known as unfractionated heparin, a highly sulfated glycosaminoglycan, is widely used as an injectable anticoagulant, and has the highest negative charge density of any known biological molecule...

  • Radiation
    Radiation
    In physics, radiation is a process in which energetic particles or energetic waves travel through a medium or space. There are two distinct types of radiation; ionizing and non-ionizing...

     induced
  • Aortic dissection
    Aortic dissection
    Aortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart. The dissection typically extends anterograde, but can extend retrograde from the site of the intimal tear. Aortic dissection is a medical...

  • Tetracyclines
    Tetracycline antibiotics
    Tetracyclines are a group of broad-spectrum antibiotics whose general usefulness has been reduced with the onset of bacterial resistance. Despite this, they remain the treatment of choice for some specific indications....

  • Postpericardiotomy syndrome
    Postpericardiotomy syndrome
    Postpericardiotomy syndrome is a medical syndrome referring to an immune phenomenon that occurs days to months after surgical incision of the pericardium...

    : Usually after CABG surgery

Laboratory tests


Laboratory values can show increased uric acid (BUN), or increased blood creatinine in cases of uremic pericarditis
Uremic pericarditis
-Presentation:Fibrinous pericarditis is an exudative inflammation. The pericardium is infiltrated by the fibrinous exudate. This consists of fibrin strands and leukocytes. Fibrin describes an amorphous, eosinophilic network. Leukocytes are found within the fibrin deposits and intrapericardic....

. Generally however, laboratory values are normal, but if there is a concurrent myocardial infarction (heart attack) or great stress to the heart, laboratory values may show increased cardiac markers like Troponin
Troponin
400px|thumb|right|alt = Colored dice with checkered background|Ribbon representation of the human cardiac troponin core complex in the calcium-saturated form...

 (I, T), CK-MB, Myoglobin
Myoglobin
Myoglobin is an iron- and oxygen-binding protein found in the muscle tissue of vertebrates in general and in almost all mammals. It is related to hemoglobin, which is the iron- and oxygen-binding protein in blood, specifically in the red blood cells. The only time myoglobin is found in the...

, and LDH
LDH
LDH is an acronym which may refer to:* Lactate dehydrogenase, an enzyme in a wide range of plants, animals and other organisms; is measured as part of the complete blood test* Large diameter hose, a type of fire hose...

1 (Lactase Dehydrogenase isotype 1). The preferred intial diagnostic testing is the EKG which will show a 12-lead electrocardiogram
Electrocardiogram
Electrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body...

 with diffuse, non-specific, concave, ST segment-elevations all leads except aVR and V1 and PR segment-depression possible in any lead except aVR; sinus tachycardia, and low-voltage QRS complexes can also be seen if there is subsymptomatic levels of pericardial effusion.

Since the mid-19th Century, retrospective diagnosis
Retrospective diagnosis
A retrospective diagnosis is the practice of identifying an illness in a historical figure using modern knowledge, methods and disease classifications...

 of pericarditis has been made upon the finding of adhesions of the pericardium. When pericarditis is diagnosed clinically, the underlying cause is often never known; it may be discovered in only 16 to 22 percent of patients with acute pericarditis.

Treatment


The treatment in viral or idiopathic pericarditis is with Aspirin
Aspirin
Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...

, or non-steroidal anti-inflammatory drug
Non-steroidal anti-inflammatory drug
Nonsteroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs, but also referred to as nonsteroidal anti-inflammatory agents/analgesics or nonsteroidal Anti-inflammatory medicines , are drugs with analgesic and antipyretic effects and which have, in higher doses, anti-inflammatory...

s (NSAIDs such as naproxen
Naproxen
Naproxen sodium is a nonsteroidal anti-inflammatory drug commonly used for the reduction of pain, fever, inflammation and stiffness caused by conditions such as:...

). Severe cases may require:
  • pericardiocentesis
    Pericardiocentesis
    In medicine, pericardiocentesis is a procedure where fluid is aspirated from the pericardium .-Position:The patient undergoing pericardiocentesis is positioned supine with the head of the bed raised to a 30- to 60-degree angle.This places the heart in proximity to the chest wall for easier...

     to treat pericardial effusion/tamponade
  • antibiotic
    Antibiotic
    An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...

    s to treat tuberculosis or other bacterial causes.
  • steroid
    Steroid
    A steroid is a type of organic compound that contains a characteristic arrangement of four cycloalkane rings that are joined to each other. Examples of steroids include the dietary fat cholesterol, the sex hormones estradiol and testosterone, and the anti-inflammatory drug dexamethasone.The core...

    s are used in acute pericarditis but are not favored because they increase chance of recurrent pericarditis.
  • colchicine
    Colchicine
    Colchicine is a medication used for gout. It is a toxic natural product and secondary metabolite, originally extracted from plants of the genus Colchicum...

     is a very effective treatment option. If Aspirin and NSAIDs are not sufficient, colchicine should be added to the regimen.
  • in rare cases, surgery
    Surgery
    Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...


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