Pericarditis

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Pericarditis
Mesothelial cyst of the pericardium. Note the rounded mass in the right costophrenic angle (arrow).
Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology
ICD-10 I01.0, I09.2, I30-I32
ICD-9 420.90
DiseasesDB 9820
MedlinePlus 000182
eMedicine med/1781  emerg/412
MeSH C14.280.720

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [3] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Overview

Diseases of the pericardium overview

Pathophysiology & Etiology

Overview | Pericarditis causes


Differential Diagnosis for Diseases of the Pericardium

Pericarditis differential diagnosis | Acute Pericarditis | Chronic Pericarditis

Clinical presentation

Chest pain, radiating to the back and relieved by sitting up forward and worsened by lying down, is the classical presentation. Other symptoms of pericarditis may include dry cough, fever, fatigue and anxiety. Pericarditis can be misdiagnosed as myocardial infarction, and vice versa.

The classic sign of pericarditis is a friction rub. Other signs include ST-elevation and PR-depression on EKG (all leads); cardiac tamponade (pulsus paradoxus with hypotension), and congestive heart failure (elevated jugular venous pressure with peripheral edema).

Natural History

Most cases of acute idiopathic pericarditis resolve without complications or recurrence. Complications may include:

Types & Forms of Pericarditis

  • A. Congenital Diseases of the Pericardium
  • B. Acquired Diseases of the Pericardium

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings

Treatment

Pharmacotherapies

Surgical and Device Based Therapies

Pericardiocentesis

A thoracoscopic approach to creating a pericardial window

A surgical subxiphoid incision to create a pericardial window

Pericardial Stripping for Constrictive Pericarditis

The definitive treatment for constrictive pericarditis is pericardial stripping, which is a surgical procedure where the entire pericardium is peeled away from the heart. This may be effective in up to 50% of patients. This procedure has significant risk involved, since the thickened pericardium is often adherent to the myocardium and coronary arteries.

In patients who have undergone coronary artery bypass surgery with pericardial sparing, there is danger of tearing a bypass graft while removing the pericardium. If any pericardium is not removed, it is possible for bands of pericardium to cause localized constriction which may cause symptoms and signs consistent with constriction.

Treatment Related Videos

  • <youtube v=lJ6KzpnjbRg/>

Complications

Fibrinous pericarditis

Pericarditis fibrinosa

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 (pink) network. Leukocytes (mainly neutrophils) are found within the fibrin deposits and intrapericardic.

Vascular congestion is also present. The myocardium has no changes. Sometimes referred to as having "Bread and Butter Appearance". Photo at: Atlas of Pathology

Pericarditis due to tuberculosis

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 diagnostic (the yield from culture is low even with optimum specimens).

The Tygerberg scoring system helps the clinician to decide whether pericarditis is due to tuberculosis or whether it is due to another cause:

  • Night sweats (1 point),
  • Weight loss (1 point),
  • Fever (2 point),
  • Serum globulin > 40g/l (3 points),
  • Blood total leucocyte count <10 x 109/l (3 points);

A total score of 6 or more is highly suggestive of tuberculous pericarditis.[1]

Pericardial fluid with an interferon-γ level greater than 50pg/ml is highly specific for tuberculous pericarditis.

The definitive treatment for constrictive pericarditis is pericardial stripping, which is a surgical procedure where the entire pericardium is peeled away from the heart. This procedure has significant risk involved,[2] with mortality rates of 6% or higher in major referral centers.[3][4] The high risk of the procedure is attributed to adherence of the thickened pericardium to the myocardium and coronary arteries. In patients who have undergone coronary artery bypass surgery with pericardial sparing, there is danger of tearing a bypass graft while removing the pericardium.

Case Examples

Case #1

Clinical Summary

This patient is a 36-year-old white male with a history of long-standing renal disease who presents with end-stage kidney disease and a BUN of 112 mg/dL. During the present hospitalization he developed a pericardial friction rub and pericardial and pleural effusions. A semi-elective pericardiectomy was performed.

Autopsy Findings

Submitted for examination was a rectangular segment of gray-tan tissue measuring 9.5 x 8.5 x 0.3 cm. The outer surface was fatty in appearance. The inner surface was rough and covered by a number of fine red papillary projections. The projections were composed of fine strands having the appearance of fibrin.

Histopathological Findings

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

This is a gross photograph of a heart illustrating acute fibrinous pericarditis. The pericardium on this heart has been reflected back (arrows). The surface of the heart is rough due to the deposition of fibrin on the epicardial surface of the heart and on the inner surface of the pericardium.


This is another view of the heart with the pericardium removed. Most of the epicardial surface is covered with fibrinous deposits as in the previous slide. There are a few glistening areas of exposed normal epicardial tissue.


This low-power photomicrograph illustrates the dark-red-staining fibrin deposits on the inner surface (arrows). This pericardium is much thicker than normal and there are numerous inflammatory cells within the pericardial tissue.


This is a higher-power photomicrograph demonstrating fronds of fibrin (arrows) projecting from the surface of the pericardium.


This high-power photomicrograph demonstrates fibrin (red amorphous material) on the surface of the pericardium (1). Note the reactive mesothelial cells on the surface of the pericardium (arrows) and the inflammatory cells within the pericardial tissue.


See Also

Source

References

  1. ↑ Reuter H, Burgess L, van Vuuren W, Doubell A. (2006). "Diagnosing tuberculous pericarditis". Q J Med. 99: 827&ndash, 39. PMID 17121764.
  2. ↑ Cinar B, Enc Y, Goksel O, Cimen S, Ketenci B, Teskin O, Kutlu H, Eren E. (2006). "Chronic constrictive tuberculous pericarditis: risk factors and outcome of pericardiectomy". Int J Tuberc Lung Dis. 10 (6): 701–6. PMID 16776460.
  3. ↑ Chowdhury UK, Subramaniam GK, Kumar AS, Airan B, Singh R, Talwar S, Seth S, Mishra PK, Pradeep KK, Sathia S, Venugopal P (2006). "Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques". Ann Thorac Surg. 81 (2): 522–9. doi:10.1016/j.athoracsur.2005.08.009. PMID 16427843.
  4. ↑ Ling LH, Oh JK, Schaff HV, Danielson GK, Mahoney DW, Seward JB, Tajik AJ (1999). "Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy". Circulation. 100 (13): 1380–6. PMID 10500037.

Acknowledgements

The content on this page was first contributed by C. Michael Gibson, M.S., M.D.

Additional Resources

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