History

Fact Explanation
Chest pain [1] Sharp pain, worsen with inspiration, worse when supine,improved when sitting up or leaning forward [1] Referred to the scapular ridge, presumably due to irritation of the phrenic nerves, which pass adjacent to the pericardium [1]
Shortness of breath [2] Due to sharp chest pain which worsen with inspiration [5]
Fever [7] Due to ongoing infection.Bacteria can spread through blood from another infection in the body, such as pneumonia [3]
Recent history of heart surgery [4] The causative organism can be introduced during the surgery [3]
Recent history of chest trauma [4] The causative organism can be introduced due to a trauma [3]
Cough [2] Due to shortness of breath and anxiety. Can also be due to a pneumonia which has given rise to the spread of the causative organism [2]
Sweating [2] Due to anxiety [2]
Immunocompromised patients/ patients with HIV [4] More prone to get bacterial pericarditis as the immune system does not function well to act against the causative agents [3]
History of chronic disease (eg: alcohol abuse, rheumatoid arthritis) [3] More prone for infections [3]
History of tuberculosis/ chronic dry cough,loss of appetite,loss of weight [3] Tuberculosis can give rise to pericarditis with the spread of the organism [3]
Ankle swelling [3] If the pericarditis is not identified and treat properly, it can give rise to complications such as heart faiure [6]
Symptoms of systemic disease eg:skin rash [1] Several types of bacteria which can give rise to systemic infections can cause bacterial pericarditis through hematigenous spread.(Pneumococci, Meningococci, Gonococci, Hemophilus, Treponema pallidum, Borreliosis, Chlamydia, Tuberculosis etc) [1]
Acutely ill and extremely toxic/confused patient [1] Due to severe infection and pain.Patient may be in septic shock [1]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  2. MAISCH B.,Guidelines on the Diagnosis and Management of Pericardial Diseases [online] 2004 [viewed 01 July 2014] Available from: http://www.escardio.org/guidelines-surveys/esc-guidelines/guidelinesdocuments/guidelines-pericardial-ft.pdf
  3. SAGRISTà SAULEDA J, PERMANYER MIRALDA G, SOLER SOLER J. [Diagnosis and management of acute pericardial syndromes]. Rev Esp Cardiol [online] 2005 Jul, 58(7):830-41 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16022815
  4. LATYSHEV Y, MATHEW A, JACOBSON JM, STURM E. Purulent pericarditis caused by Haemophilus parainfluenzae. Tex Heart Inst J [online] 2013, 40(5):608-11 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24391338
  5. SIRIJATUPHAT R, NILTWAT S, TIANGTAM O, TUNGSUBUTRA W. Purulent pericarditis and cardiac tamponade caused by Nocardia farcinica in a nephrotic syndrome patient. Intern Med [online] 2013, 52(19):2231-5 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24088757
  6. PORRES-AGUILAR M, FLAVIN NE, FLEMING RV, LALUDE O. Severe bivalvular pneumococcal endocarditis and suppurative pericarditis in an immunocompetent patient. Intern Med [online] 2010, 49(4):321-3 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20154438
  7. NAGANO N, YAMAMOTO T, AMANO A, KIKUCHI K. Infected aneurysm of the aortic arch with purulent pericarditis caused by Streptococcus pneumoniae. Interact Cardiovasc Thorac Surg [online] 2010 Mar, 10(3):459-61 [viewed 14 September 2014] Available from: doi:10.1510/icvts.2009.224980

Examination

Fact Explanation
Pericardial friction rub [1] Due to fluid in between the pericardial layers.Scratchy superficial sound that is heard most strongly in the mesocardium and the lower left parasternal edge and that varies in strength with respiratory movements [1]
Dyspnea/ hyperventilation [2] Pain leading to shortness of breath or may be due to an on going pneumonia. systemic inflammatory response syndrome may be present due to severe infection which give rise to hyperventilation [2]
Signs of septic shock-Tachycardia , low blood pressure,confused patient [2] Severe systemic infection can lead to septic shock [2]
Scar marks due to recent surgeries [2] Organism may be introduced during surgery or chest trauma [2]
Pulsus paradoxus ( abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration ) [2] Due to cardiac tamponade.(Bacterial pericarditis can lead to cardiac tamponade) [2]
Beck's triad - low blood pressure (due to decreased cardiac output), muffled heart sounds and distension of the jugular vein [2] Due to cardiac tamponade.(Bacterial pericarditis can lead to cardiac tamponade) [2]
Patient in pain [1] Chest pain is a feature of pericarditis and pressure over the sternum increases the chest pain [2]
Wasted apparance [3] Due to tuberculosis which can give rise to pericarditis [3]
Skin rash [1] Due to the primary infection.Several types of bacteria which can give rise to systemic infections can cause bacterial pericarditis through hematogenous spread.(Pneumococci, Meningococci, Gonococci, Haemophilus, Treponema pallidum, Borreliosis, Chlamydia, Tuberculosis etc) [1]
Ankle oedema [2] , hepatomegaly [4] If not properly treated, patients may go into heart failure [2]
References
  1. SAGRISTà SAULEDA J, PERMANYER MIRALDA G, SOLER SOLER J. [Diagnosis and management of acute pericardial syndromes]. Rev Esp Cardiol [online] 2005 Jul, 58(7):830-41 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16022815
  2. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  3. MAISCH B.,Guidelines on the Diagnosis and Management of Pericardial Diseases [online] 2004 [viewed 01 July 2014] Available from: http://www.escardio.org/guidelines-surveys/esc-guidelines/guidelinesdocuments/guidelines-pericardial-ft.pdf
  4. FEINSTEIN Y, FALUP-PECURARIU O, MITRICă M, BEREZIN EN, SINI R, KRIMKO H, GREENBERG D. Acute pericarditis caused by Streptococcus pneumoniae in young infants and children: three case reports and a literature review. Int J Infect Dis [online] 2010 Feb, 14(2):e175-8 [viewed 14 September 2014] Available from: doi:10.1016/j.ijid.2009.03.033

Differential Diagnoses

Fact Explanation
Myocardial ischemia / infarction [1] Chest pain does not change with respiration or with position.Pain respond to Response to nitroglycerin.Electrocardiogram shows ST elevations or depressions.Friction rub is absent on examination [1]
Pulmonary embolsm [1] Sharp,stabbing chest pain which does not change with position.ST elevations limited to lead III, aVF, and V1 [1]
Viral pericarditis [2] Serous/serosanguinous small effusions may be present.Leukocyte count in pericardial effusion- >5000/ml. Pericardial fluid analyses shows activated lymphocytes [2]
Autoreactive pericarditis [2] Occurs due to an autoimmune process in the absence of viral and bacterial agents.Associated other autoimmune disorders may be present. Pericardial fluid analysis shows activated lymphocytes. [2]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  2. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 01 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002

Investigations - for Diagnosis

Fact Explanation
Electrocardiogram [1] ST segment - widespread concave Frequent PR segment depression. [1]
Pericardial fluid analysis [1] Percutaneous pericardiocentesis must be promptly performed. Obtained pericardial fluid should undergo urgent Gram, acid-fast staining. Bacterial pericarditis- Purulent fluid,high protein content,leukocyte >10000/ml,massive granulocytes and macrophages Tuberculous pericarditis- positive acid fast staining.Serosanguinous fluid, leukocyte >8000/ml,positive adenosine deaminase levels ( >40u/ml ),positive PCR analysis[2]
Blood culture & antibiotic sensitivity testing [2] To detect the causative organism as it can spread through blood.Also to check the drug sensitivity [2]
Chest x ray [3] In pericarditis with mild or no effusion heart appears normal in x ray.Cardiomegaly appears when the effusion exceeds 250 ml [3] Also a pneumonia may be evident in chest x ray [1]
Echocardiography [3] Echocardiography is the most useful diagnostic technique for identifying the presence of pericardial effusion and quantifying its extent [3]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  2. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 01 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  3. SAGRISTà SAULEDA J, PERMANYER MIRALDA G, SOLER SOLER J. [Diagnosis and management of acute pericardial syndromes]. Rev Esp Cardiol [online] 2005 Jul, 58(7):830-41 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16022815

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] High levels of white blood cell counts with increased neutrophil count [1]
C reactive protein levels [1] Acute phase proteins will be elevated [1]
References
  1. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 01 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002

Investigations - Followup

Fact Explanation
Full blood count [1] The white blood cell count will reduce with the treatment [1]
Echocardiography [3] Echocardiography is the most useful diagnostic technique for identifying the presence of pericardial effusion and quantifying its extent [2]
References
  1. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 01 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  2. SAGRISTà SAULEDA J, PERMANYER MIRALDA G, SOLER SOLER J. [Diagnosis and management of acute pericardial syndromes]. Rev Esp Cardiol [online] 2005 Jul, 58(7):830-41 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16022815
  3. LATYSHEV Y, MATHEW A, JACOBSON JM, STURM E. Purulent pericarditis caused by Haemophilus parainfluenzae. Tex Heart Inst J [online] 2013, 40(5):608-11 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24391338

Investigations - Screening/Staging

Fact Explanation
Electrocardiogram [1] ST segment - widespread concave Frequent PR segment depression [1]
Chest x ray [3] Cardiomegaly will be evident if there's a pericardial effusion >250ml or if the condition has complicated with heart failure [2]
Echocardiography [2] Echocardiography is the most useful diagnostic technique for identifying the presence of pericardial effusion and quantifying its extent [2]
Troponin I [2] May be elevated as patients may have varying degrees of myocarditis [2]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514
  2. SAGRISTà SAULEDA J, PERMANYER MIRALDA G, SOLER SOLER J. [Diagnosis and management of acute pericardial syndromes]. Rev Esp Cardiol [online] 2005 Jul, 58(7):830-41 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16022815
  3. LATYSHEV Y, MATHEW A, JACOBSON JM, STURM E. Purulent pericarditis caused by Haemophilus parainfluenzae. Tex Heart Inst J [online] 2013, 40(5):608-11 [viewed 14 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24391338

Management - General Measures

Fact Explanation
Non steroidal anti inflammatory drugs (NSAIDs) [1] For pain relief [1]
Asprin [1] Preferred agent to treat pericarditis after MI (myocardial infarction) as other NSAIDs may interfere with myocardial healing [1]
Colchicine [1] If the pericardial pain and inflammation do not respond to NSAIDs or if the acute pericarditis recurs, colchicine has been observed to be effective in relieving pain and preventing recurrent pericarditis [1]
References
  1. LITTLE W. C.. Pericardial Disease. Circulation [online] 2006 March, 113(12):1622-1632 [viewed 01 July 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.561514

Management - Specific Treatments

Fact Explanation
Intravenous antibiotic therapy [1] Effective systemic antibiotic therapy is mandatory (antistaphylococcal antibiotic plus aminoglycoside, followed by tailored antibiotic therapy according to pericardial fluid and blood cultures) [1]
Treatment for tuberculous pericarditis [2] Various combinations of anti tuberculous drugs (Isoniazid,rifampicin,ethambutol and pyrazinamide ) of different lengths (6,9,12 months) have been applied [2]
Surgical [2] Frequent irrigation of the pericardial cavity with urokinase or streptokinase, using large catheters, may liquefy the purulent exudate, but open surgical drainage through subxiphoid pericardiotomy is preferable. [2]
Pericardiectomy [2] Required in patients with dense adhesions, thick purulent effusion, recurrence of tamponade [2]
References
  1. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 01 July 2014] Available from: doi:10.1016/j.ehj.2004.02.002
  2. MAISCH B.,Guidelines on the Diagnosis and Management of Pericardial Diseases [online] 2004 [viewed 01 July 2014] Available from: http://www.escardio.org/guidelines-surveys/esc-guidelines/guidelinesdocuments/guidelines-pericardial-ft.pdf