Haemophilus influenzae pericarditis with tamponade as the initial presentation of systemic lupus erythematosus

Although cardiac tamponade is an important and emergent complication of systemic lupus erythematosus (SLE), purulent pericarditis is rare despite the high frequency of pericardial effusion in SLE. We describe the first SLE case of Haemophilus influenzae type-f pericarditis with cardiac tamponade with SLE as the initial presentation. The pathophysiology and therapy are discussed.     

Spectrum of pericardial disease: part II

Pericardial disease is a common disorder seen in varying clinical settings, and may be the first manifestation of an underlying systemic disease. In part I, we focused on the current knowledge and management of the more common pericardial diseases: acute pericarditis, pericardial effusion, cardiac tamponade, chronic pericarditis and relapsing pericarditis. In part II, we will focus on the knowledge and management of pericardial involvement in chylous pericardial effusion cholesterol pericarditis, radiation pericarditis, pericardial involvement in systemic inflammatory diseases, autoreactive pericarditis, pericarditis in renal failure, pericardial constriction and effusive constrictive pericarditis.     

Pericarditis, pericardial effusion, cardiac tamponade, and constriction

Critical care aspects of pericardial disease are covered, including diagnosis and differential diagnosis of acute pericarditis, pericardial effusion with and without cardiac tamponade, constrictive pericarditis and effusive-constrictive pericarditis. Emphasis is placed on clinical signs and the important invasive and noninvasive diagnostic procedures, particularly various imaging methods (emphasis on echocardiography), electrocardiography, and cardiac catheterization. Medical and surgical therapies are reviewed, and the technique of pericardiocentesis is presented.     

Spectrum of pericardial disease: part I

Pericardial disease is a common disorder seen in varying clinical settings and may be the first manifestation of an underlying systemic disease. It may be due to multiple causes. Epidemiologic studies are lacking, and the exact incidence and prevalence are unknown. New diagnostic techniques have improved diagnosis, allowing early diagnosis and management. There are few randomized data to guide physicians in the management of pericardial diseases. Part I of our review focuses on the current state of knowledge and management of the more common pericardial diseases: acute pericarditis, pericardial effusion, cardiac tamponade, chronic pericarditis and relapsing pericarditis.     

Pericardial Disease: Diagnosis and Management

Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Clinicians are often faced with several diagnostic and management questions relating to the various pericardial syndromes: What are the diagnostic criteria for the vast array of pericardial diseases? Which diagnostic tools should be used? Who requires hospitalization and who can be treated as an outpatient? Which medical management strategies have the best evidence base? When should corticosteroids be used? When should surgical pericardiectomy be considered? To identify relevant literature, we searched PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Studies were selected on the basis of clinical relevance and the impact on clinical practice. This review represents the currently available evidence and the experiences from the pericardial clinic at our institution to help guide the clinician in answering difficult diagnostic and management questions on pericardial diseases.CMR = cardiac magnetic resonance imaging; CT = computed tomography; CYP = cytochrome P450; ECG = electrocardiographic; ESC = European Society of Cardiology; IVC = inferior vena cava; LV = left ventricular; NSAID = nonsteroidal anti-inflammatory drug; RA = right atrium; RV = right ventricleThe pericardium is a thin covering that separates the heart from the remaining mediastinal structures and provides structural support while also having a substantial hemodynamic impact on the heart. The pericardium is not essential—normal cardiac function can be maintained in its absence—however, diseased pericardium presenting clinically as acute or chronic recurrent pericarditis, pericardial effusion, cardiac tamponade, and pericardial constriction can be challenging to manage and life-threatening in some cases. The etiology of pericardial disease is often difficult to determine or remains idiopathic. However, microorganisms, including viruses and bacteria; systemic illnesses, including neoplasia, autoimmune disease, and connective tissue disease; renal failure; previous cardiac surgery; previous myocardial infarction; trauma; aortic dissection; radiation; and, rarely, drugs have been associated with pericardial diseases.The diagnosis and management of pericardial diseases remain challenging because of the vast spectrum of manifestations and the lack of clinical data on which to base guidelines by the American College of Cardiology and the American Heart Association. However, the European Society of Cardiology (ESC) published guidelines on pericardial disease in 2004.¹ This review aims to describe the methods of diagnosing and managing major pericardial syndromes on the basis of the literature and the clinical experience of our pericardial clinic. Searches were performed on PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. No date limitations were set. Studies were selected on the basis of clinical relevance and the impact on clinical practice.     

MR imaging of the pericardium

Imaging of the pericardium requires understanding of anatomy and the normal and abnormal physiology of the pericardium. MR imaging is well-suited for answering clinical questions regarding suspected pericardial disease. Pericardial diseases that may be effectively imaged with MR imaging include pericarditis, pericardial effusion, cardiac-pericardial tamponade, constrictive pericarditis, pericardial cysts, absence of the pericardium, and pericardial masses. Although benign and malignant primary tumors of the pericardium may be occasionally encountered, the most common etiology of a pericardial mass is metastatic disease.     

Purulent pericarditis misdiagnosed as septic shock

BACKGROUND: Septic shock is common, with approximately 200,000 cases recognized annually. This syndrome is so well characterized that when a patient is febrile and in shock, septic shock may be diagnosed without regard to alternative possibilities. Purulent pericarditis is a relatively rare disorder in which fever and hypotension are common. Classic signs and symptoms, such as chest pain, pericardial friction rub, pulsus paradoxus, and elevation of jugular venous pressure, are seen in only 50%. METHODS: In this report, we describe four patients in whom purulent pericarditis and pericardial tamponade was initially misdiagnosed as septic shock. During a 3-month period, three men and one woman (mean age, 44.5 years) came to Kern Medical Center with purulent pericarditis and pericardial tamponade. These cases represented 13% of patients admitted with a diagnosis of septic shock. RESULTS: All patients were bacteremic, and the classic findings of pericardial tamponade were absent or relatively subtle. Hemodynamic findings of elevated systemic vascular resistance, low cardiac output, and normal pulmonary artery occlusion pressure were critical to the diagnosis. CONCLUSIONS: Consideration of purulent pericarditis is important in cases diagnosed as septic shock. Clinicians should be aware that patients with purulent pericarditis may not exhibit classic signs and symptoms, and a high index of suspicion is necessary for appropriate management.     

Postpacemaker implant pericarditis: incidence and outcomes with active-fixation leads

Pericarditis has been noted as a potential complication of pacemaker implantation. This study evaluated the risk of developing pericarditis following pacemaker implantation with active-fixation atrial leads. Included were 1,021 consecutive patients (mean age 73.4+/-0.4 years, range 16-101 years; 45.2% women) undergoing new pacemaker system implantation between 1991 and 1999 who were reviewed for the complication of pericarditis. The incidence and outcomes of postimplantation pericarditis in patients receiving active-fixation atrial leads were compared to those not receiving these leads. Of 79 patients who received active-fixation atrial leads, 4 (5%) developed pericarditis postpacemaker implantation. Of 942 patients with passive-fixation atrial leads or no atrial lead (i.e., a ventricular lead only), none developed pericarditis postoperatively (P < 0.001). Of patients receiving active-fixation ventricular leads only (n = 97), none developed pericarditis. No complications were apparent at the time of implantation in patients who developed pericarditis. Pleuritic chest pain developed between 1 and 28 hours postoperatively. Three patients had pericardial rubs without clinical or echocardiographic evidence of tamponade. They were treated conservatively with acetylsalicylic acid or ibuprofen and their symptoms resolved without sequelae in 1-8 days. One patient (without pericardial rub) died due to cardiac tamponade on postoperative day 6. Postmortem examination revealed hemorrhagic pericarditis with no gross evidence of lead perforation. Pericarditis complicates pacemaker implantation in significantly more patients who receive active-fixation atrial leads. It may be precipitated byperforation of the atrial lead screw through the thin atrial wall. Patients developing postoperative pericarditis should befollowed closely due to the risk of cardiac tamponade.     

Hypothyroidism presenting as acute cardiac tamponade with viral pericarditis

This report describes the case of a young woman who presented to an emergency department with severe abdominal pain and shock. The patient was found to have pericardial tamponade due to a massive pericardial effusion. On further evaluation, the etiology of this effusion was considered to be secondary to hypothyroidism with concominant acute viral pericarditis leading to a fulminant tamponade. The presentation, differential diagnosis, and management of pericardial effusion and tamponade secondary to hypothyroidism and viral pericarditis are discussed. The diagnosis of hypothyroidism in conjunction with acute viral pericarditis should be considered in patients presenting with unexplained pericardial effusion and tamponade.     

Pericardiocentesis.

Cardiac tamponade is a life-threatening condition resulting from compression of the cardiac chambers by a pericardial effusion. The principal cause of pericardial effusion is malignant disease of the pericardium, but infectious causes and cardiac trauma are common as well. The patient with cardiac tamponade demonstrates an abnormal pulsus paradoxus, and clinical signs of shock and impending cardiovascular collapse occur with very severe cardiac compression. Relief of the increased intrapericardial pressure is mandatory to establish adequate cardiac output. The definitive treatment of cardiac tamponade is emergent removal of enough pericardial fluid to acutely lower intrapericardial pressure. Echocardiographic guidance may be used if immediately available, but is not required to perform pericardiocentesis in a critical situation. Placement of a pulmonary artery catheter prior to pericardiocentesis is not indicated in cardiac tamponade. Once cardiac output and tissue perfusion have been restored, further drainage procedures such as pericardial catheter placement or surgical drainage are indicated. Therapeutic measures to address the underlying disease process should be initiated after pericardial drainage is accomplished.     

Cardiac tamponade as a manifestation of tuberculosis

Tuberculosis has been increasing in incidence in recent years. Pericardial involvement and pericardial effusions are well-documented and may result in pericardial tamponade. Despite this, large pericardial effusions are uncommon, and manifestation as cardiac tamponade is rare. We report two cases of tuberculous pericarditis in which the initial feature was tamponade. Since the diagnosis of tuberculosis may be delayed due to the slow-growing nature of the bacterium, physicians need to be aware of this possibility and consider the use of modern diagnostic techniques that may permit an earlier diagnosis.     

Contemporary management of pericardial effusion: practical aspects for clinical practice

A pericardial effusion (PE) is a relatively common finding in clinical practice. It may be either isolated or associated with pericarditis with or without an underlying disease. The aetiology is varied and may be either infectious (especially tuberculosis as the most common cause in developing countries) or non-infectious (cancer, systemic inflammatory diseases). The management is essentially guided by the hemodynamic effect (presence or absence of cardiac tamponade), the presence of concomitant pericarditis or underlying disease, and its size and duration. The present paper reviews the current knowledge on the aetiology, classification, diagnosis, management, therapy, and prognosis of PE in clinical practice.     

A simple method for continuous pericardial drainage

Needle pericardiocentesis is performed routinely for relief of symptoms in patients with pericardial effusion and cardiac tamponade. In many patients however, reaccumulation of fluid requires further aspiration or surgical drainage, occasionally as a matter of urgency. Both procedures carry significant risks which may be avoided by insertion of an indwelling catheter. The Viggo subclavian cannula proves ideal for prolonged drainage of pericardial effusions and for relief of tamponade in an emergency situation. Introduction into the pericardium is simple, safe, and can be performed quickly without specialised equipment. This procedure is described and illustrated in patients with tuberculous and rheumatoid pericarditis.     

Pericardial disease: a clinical review

Pericardial disease is infrequently encountered in cardiovascular practice, but can lead to significant morbidity and mortality. Clinical data and practice guidelines are relatively sparse. Early recognition and prompt treatment of pericardial diseases are critical to optimize patient outcomes. In this review we provide a concise summary of acute pericarditis, constrictive pericarditis and pericardial effusion/tamponade.     

Diagnosing pericarditis

Pericarditis, or inflammation of the pericardium, is most often caused by viral infection. It can also develop as a result of bacterial or other infection, autoimmune disease, renal failure, injury to the mediastinal area, and the effects of certain drugs (notably hydralazine and procainamide). The clinical features of pericarditis depend on its cause, as well as the volume and type of effusion. Patients with uncomplicated pericarditis have pleuritic-type chest pain that radiates to the left shoulder and may be relieved by leaning forward. Chest radiographs, Doppler studies, and laboratory tests confirm the diagnosis and provide information about the degree of effusion. In most patients, pericarditis is mild and resolves spontaneously, although treatment with a nonsteroidal anti-inflammatory drug or a short course of a corticosteroid may be helpful. When a large pericardial effusion is produced, cardiac function may be compromised, and cardiac tamponade can occur. In patients with longstanding inflammation, the pericardium becomes fibrous or calcified, resulting in constriction of the heart. Drainage or surgical intervention may be necessary in patients with complicated pericarditis.     

Diagnostic issues in the clinical management of pericarditis

Aims: To review the current major diagnostic issues on the diagnosis of acute and recurrent pericarditis. Methods: To review the current available evidence, we performed a through search of several evidence‐based sources of information, including Cochrane Database of Systematic Reviews, Clinical Evidence, Evidence‐based guidelines from National Guidelines Clearinghouse and a comprehensive Medline search with the MeSH terms ‘pericarditis’, ‘etiology’ and ‘diagnosis’. Results: The diagnosis of pericarditis is based on clinical criteria including symptoms, presence of specific physical findings (rubs), electrocardiographical changes and pericardial effusion. Although the aetiology may be varied, most cases are idiopathic or viral, even after an extensive diagnostic evaluation. In such cases, the course is often benign following anti‐inflammatory treatment, and management would be not affected by a more precise diagnostic evaluation. A triage of pericarditis can be safely performed on the basis of the clinical and echocardiographical presentation. Specific diagnostic tests are not warranted if no specific aetiologies are suspected on the basis of the epidemiological background, history and presentation. High‐risk features associated with specific aetiologies or complications include: fever > 38 °C, subacute onset, large pericardial effusion, cardiac tamponade, lack of response to aspirin or a NSAID. Conclusions: A targeted diagnostic evaluation is warranted in acute and recurrent pericarditis, with a specific aetiological search to rule out tuberculous, purulent or neoplastic pericarditis, as well as pericarditis related to a systemic disease, in selected patients according to the epidemiological background, presentation and clinical suspicion.     

A review of pericardial diseases: clinical, ECG and hemodynamic features and management

Pericardial diseases are common, have multiple causes, and are often misdiagnosed. Physicians need to recognize the characteristic and distinguishing features of the three most important pericardial conditions: acute pericarditis, cardiac tamponade, and constrictive pericarditis. In these conditions, proper diagnosis and appropriate management can significantly reduce morbidity and mortality.     

Uremic pericarditis in patients with End Stage Renal Disease: Prevalence,symptoms and outcome in 2017

The prevalence of uremic pericarditis (UP) used to range from 3% to 41%. More recently, it has decreased to about 5%–20% and to < 5% in the last decades, as hemodialysis techniques have become widely used and dialysis quality improved. The objective of this work is to determine the initial clinical picture and the prognosis of patients presenting End Stage Renal Disease (ESRD) with UP. Materials: This is a retrospective study (May 2015–September 2017). Inclusion criteria targeted patients who had uremic pericarditis defined as pericarditis occurring in a patient with ESRD before initiation of renal replacement therapy, or within eight weeks of its initiation. Results: 16 patients met the inclusion criteria. The median age of patients was 54 [24, 71] years and 56.2% were male. Pericardial effusion was small, moderate and large in 31.2%, 37.6% and 31.2% of cases respectively. One pericardiocentesis was performed in view of a clinical picture of impending cardiac tamponade and three pericardial drainages were performed given presentation of tamponade. Hemodialysis was initiated for all the patients and continued for 2 to 3 weeks until complete regression of the pericardial effusion. The mean number of dialysis sessions was 11 ± 3.5. One patient died of septic shock that developed three weeks after diagnosis of uremic pericarditis. Conclusion: UP is considered a rare but fatal complication of ESRD because of the risk of tamponade and its prognosis remains dependent on early diagnosis and adequate treatment of ESRD.     

Acute pericarditis

Although acute pericarditis is most often associated with viral infection, it may also be caused by many diseases, drugs, invasive cardiothoracic procedures, and chest trauma. Diagnosing acute pericarditis is often a process of exclusion. A history of abrupt-onset chest pain, the presence of a pericardial friction rub, and changes on electrocardiography suggest acute pericarditis, as do PR-segment depression and upwardly concave ST-segment elevation. Although highly specific for pericarditis, the pericardial friction rub is often absent or transient. Auscultation during end expiration with the patient sitting up and leaning forward increases the likelihood of observing this physical finding. Echocardiography is recommended for most patients to confirm the diagnosis and to exclude tamponade. Outpatient management of select patients with acute pericarditis is an option. Complications may include pericardial effusion with tamponade, recurrence, and chronic constrictive pericarditis. Use of colchicine as an adjunct to conventional nonsteroidal anti-inflammatory drug therapy for acute viral pericarditis may hasten symptom resolution and reduce recurrences.     

Thoracoscopic pericardiotomy for management of purulent pneumococcal pericarditis in a child

Purulent pericarditis is an extremely rare complication of pneumococcal pneumonia in children that may result in to cardiac tamponade. While image-guided pericardiocentesis is the treatment of choice for such a condition, it may fail in the presence of thick pus; loculations and thoracoscopic pericardiotomy are useful procedures for such situations. Herein, we report such a case involving a 6-year-old boy who presented with purulent pneumococcal pericarditis that was managed with thoracoscopic pericardiotomy and who recovered well. Thoracoscopic pericardiotomy is a safe procedure that allows effective drainage under vision, pericardial biopsy for diagnosis, and a simultaneous opportunity to perform thoracoscopic pleural drainage.