Differentiating COVID-19-associated pericarditis from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]

Overview

COVID-19-associated pericarditis must be differentiated from other causes of dyspnea and chest pain, such as myocarditis, heart failure, acute coronary syndrome, pneumonia and pulmonary embolism.

Differential Diagnosis

COVID-19-associated pericarditis must be differentiated from other causes of dyspnea and chest pain, such as myocarditis, heart failure, acute coronary syndrome, pneumonia and pulmonary embolism.

Diseases Symptoms Physical Examination Diagnostic tests Other Findings
Dyspnea on Exertion Chest Pain Hemoptysis Fever Tachypnea Tachycardia Chest X-ray ECG Echocardiography CT scan and CMR
COVID-19-associated pericarditis ✔ (relieves on sitting or leaning forward) - -
  • ST elevation and PR depression are seen but these changes are not specific to COVID-19 pericarditis.
  • Non-specific ST changes
  • T wave inversion in the inferior leads (II, III and aVF)
  • Small to moderate pericardial effusion.
  • In the cases complicated by cardiac tamponade, findings included:
    • Large pericardial effusion
    • Right ventricular diastolic collapse
    • Increased respiratory variation in peak E-wave mitral inflow velocity
    • Dilated inferior vena cava
  • CT: Pericardial effusion
  • CMR: late gadolinium sequences done to rule out myocarditis showed extensive enhancement of the walls of the heart and the pericardium in two of the reported cases.
  • On physical exam, Pericardial friction rub may be heard; tachycardia, hypotension and distant heart sounds seen in cardiac tamponade
  • Increased cardiac troponin level, CK level; increase in inflammatory markers levels.
COVID-19-associated myocarditis - Increased cardiac troponin level
COVID-19-associated myocardial infarction - ✔(Low-grade) ✔/- ✔/-
  • No specific X-ray findings
  • Localized wall motion abnormalities
  • Diffuse hypokinesia
  • Left ventricular ejection fraction was lower than 50% in about 61% of the individuals.

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Increased cardiac troponin levels
COVID-19-associated heart failure - - Increased NT-proBNP and cardiac troponins levels
COVID-19-associated pneumonia ✔ (Pleuritic) ✔ (Usually high) - Increased inflammatory markers, including ESR, hs-CRP
COVID-19-associated acute respiratory distress syndrome - -
  • Signs of RV dysfunction/RV dilatation may be seen.
-
COVID-19-associated pulmonary embolism ✔ (Usually sudden-onset) ✔ (Pleuritic) ✔ (If massive PE) ✔ (Low-grade)
  • Non-specific:may show S1Q3T3 pattern
  • May show signs of RV strain, RV dilatation, RV dysfunction (if large PE)
  • On CT angiography: Intra-luminal filling defect
  • On MRI: Narrowing of involved vessel
  • No contrast seen distal to obstruction
  • Polo-mint sign (partial filling defect surrounded by contrast)


References