Acute Pericarditis

So, I was in A&E one day and I took a history and did a cardiac examination on a middle aged man presenting with chest pain. He had a recent history of flu-like symptoms- runny nose, fever and bit of a cough- and recent onset chest pain that went and came and that was made better when leaning forward and worse on inspiration. Aha! It’s pericarditis! Super impressed with my rapidly progressing diagnostic abilities 🙂

Checked his ECG- completely normal.

Asked the doctor- ‘most likely just a flu’.

Oh.

The patient’s English was very poor and it took me a very long time to get his history with me struggling to communicate my questions to him. He had flu-like symptoms, which precede all cases of pericarditis in medical school exam questions, and so I diagnosed him and then directed him to answer yes to the rest of my questions so that it would all add up.


Acute Pericarditis

Definition: inflammation of the pericardium

Image result for pericardium

Can lead to-

Pericardial effusion– accumulation of fluid in the pericardial sac

Cardiac tamponade– accumulation of pericardial fluid raises intrapericardial pressure, hence poor ventricular filling and fall in cardiac output

Aetiology/ risk factors:

-May be idiopathic or secondary to:

-Viruses (Coxsackie, flu, EBV, mumps, varicella, HIV)

-Bacteria (pneumonia, rheumatic fever, TB, staphs, streps, MAI in HIV)

-Fungi

-Post-MI (24-72h)

-Drugs: procainamide, hydralazine, penicillin, cromolyn sodium, isoniazid

-Malignancy: lung, breast, lymphoma, leukaemia, melanoma

-Others: uraemia, rheumatoid arthritis, SLE, myxoedema, trauma, thoracic surgery, radiotherapy, sarcoidosis.

Dressler’s Syndrome: 2-10 weeks after MI, heart surgery or even pacemaker insertion.

Thought that myocardial injury stimulates formation of auto-antibodies against heart muscle.

Epidemiology: uncommon, < 1 in 100 hospital admissions, more common in males

Symptoms:

sharp and central chest pain, worse on deep inspiration (and coughing) and lying flat, relieved by sitting forwards

-pain may radiate to neck or shoulders

-fever and nausea may occur

-may be preceded by flu symptoms: e.g. fever, runny nose, myalgia

-dyspnoea (esp. if pericardial effusion)

Signs:

-pericardial friction rub may be heard on auscultation (best heard at lower left sternal edge with patient leaning forward in expiration)

signs of pericardial effusion:

-raised JVP (with prominent x descent)

-bronchial breathing at left base (large effusion compressing left lower lobe)

signs of cardiac tamponade:

-increased pulse

-decreased blood pressure

-pulsus paradoxus- abnormally large decrease in systolic BP and pulse wave amplitude during (> 10 mmHg drop)

-raised JVP

-Kussmaul’s sign (JVP rises with inspiration)

-muffled heart sounds

(Beck’s triad = falling BP, rising JVP, muffled heart sounds)

Dressler’s syndrome: recurrent fever, chest pain +/- pleural or pericardial rub

Investigations:

ECG: diffuse saddle shaped (concave) ST elevation, that is not confined to a single coronary artery territory

Image result for pericarditis ecg

-ECG may be normal or non-specific (10%)

-Pericardial effusion/ cardiac tamponade:  ECG shows low voltage QRS complexes, and alternating QRS morphologies (electrical alternans)

Image result for electrical alternans pericardial effusion

Bloods: FBC (↑WCC), ESR (↑), U&Es, cardiac enzymes (troponin may be raised), viral serology, blood cultures

 If indicated- auto-antibodies (Rh factor, ANA), fungal precipitins, thyroid function tests

CXR: cardiomegaly may indicate a pericardial effusion/tamponade. The heart is enlarged and globular (if > 250 ml effusion)

Image result for cxr pericardial effusion

Echocardiogram: if pericardial effusion/ tamponade suspected, echo is diagnostic. Shows an echo-free zone surrounding the heart, +/- diastolic collapse of right atrium and right ventricle in tamponade

Image result for echo pericardial effusion

Management:

Analgesia: e.g. NSAIDs- ibuprofen (400mg/8h PO)

Treat cause

-Consider colchicine before steroids/ immunosuppressants if relapse or continuing symptoms.

Pericardial effusion/ tamponade: pericardiocentesis may be diagnostic (suspected bacterial pericarditis) or therapeutic (urgent drainage in tamponade). Send pericardial fluid for culture, ZN stain/TB culture, and cytology.

Complications:

-Pericardial effusion

-Cardiac tamponade

(Other causes of cardiac tamponade: aortic dissection, haemodialysis, warfarin, trans-septal puncture at cardiac catheterisation, post-cardiac biopsy)

-Constrictive pericarditis

-Cardiac arrhythmias

Prognosis:

-depends on underlying cause

-good prognosis in viral cases (within ~ 2 weeks) and poor in malignant pericarditis

-15-40% do recur

-steroids may increase the risk of recurrence

(Actually, after reading up on this condition, he might very well have had pericarditis. Maybe…)

References: Cheese & Onion, Rapid Medicine

 

 

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