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Sunday, April 12, 2009

Acute Nonsuppurative Pericarditis

12:35 PM


ALSO KNOWN AS
Pericarditis, ANP, Constrictive Pericarditis, CP, or pericardial tamponade

DESCRIPTION
* The heart and the blood vessels emerging from it are covered by a sac called the pericardium. This sac has an outer and inner layer normally separated by a small amount of lubricating fluid. Conditions that irritate the pericardium cause a localized and protective body response known as inflammation. This may result in an increase in the amount of fluid (pericardial effusion) between the outer and inner layers that may compress the heart and restrict its pumping action.
* In constrictive Pericarditis there is a thickening of the pericardium and attachment to the heart that may restrict its normal movements.
* In pericardial or Cardiac Tamponade (PT), blood or fluid can also collect in the pericardium and cause heart problems. PT can result with any type of Pericarditis.
* Pericarditis may be acute (less than 6 weeks) or chronic (>6 weeks).


SYMPTOMS
* Chest pain:

1. Sharp or stabbing
2. Sudden
3. Worse on breathing in or with movement
4. Radiating to neck, back, shoulders, or abdomen
5. Reduced by sitting up or leaning forward

* Difficulty breathing:

1. Worse with lying down
Better when standing, sitting, or bent forward
2. Racing Heart
3. Pounding in the Chest
4. Fever
5. Cough
6. Sweating
7. Dizziness
8. Fatigue
9. Loss of appetite

* With constrictive Pericarditis and Pericardial Tamponade, there is pressure on the heart from thick fibrous material or fluids (>120cc) that compromises the heart's ability to pump, and fluids may build up in the abdomen, ankles, and feet (right-sided Heart Failure).

CAUSE
*
Idiopathic -- i.e., no cause is identified. This is the most common type.
*
Infections:

1.
Viruses -- Coxsackie B (especially children), adenovirus (especially children), Mumps , Epstein-Barr, echo virus, Herpes Simplex
2. Bacteria -- Staphylococcus, Haemophilus (especially children), pneumococcus,
Salmonella, Lyme Disease, meningococcus, mycoplasma
3. Acute Rheumatic Fever
4. Mycobacterium -- M.Tuberculosis
5. Fungi -- candida, nocardi, Histoplasmosis
6.
Parasites

* Drugs:

1. Phenytoin
2. Procainamide
3. Hydralazine
4. Minoxidil

* Others:

1. Cancers:
2. Lung
3. Breast
4. Lymphoma
5. Mesothelioma -- tumors caused by exposure to asbestos

* Connective tissue diseases:

1. Rheumatoid Arthritis
2. SLE ( Systemic Lupus Erythematosus )

* Diseases and other conditions:

1. Pancreatitis
2. Uremia -- kidney failure
3. Sarcoidosis
4. AIDS
5. Aortic Dissection -- aorta (major artery) can rupture
6. Chylopericardium (milky fluid inside the pericardium)
7. Myxedema -- severe thyroid disease
8. Dressler's syndrome -- Pericarditis long after a heart attack
9. Radiation of any cause -- constrictive Pericarditis
10. Radiation therapy
11. Acute Pericarditis can result in Pericardial Tamponade and can lead to chronic or constrictive Pericarditis.

HOW THE DIAGNOSIS IS MADE
* Examination and history
* Physician may consult with a heart specialist (cardiologist)
* History:

1. Symptoms
2. Medications
3. Illnesses
4. Surgeries
5. Habits
6. Job
7. Family
8. Travel
9. Allergies

*
Exam:

o Acute Pericarditis:

1. Patient is in pain and anxious.
2. Patient is leaning forward and unable to lie flat.
3. Rapid shallow breathing may be present.
4. Doctor may hear a friction rub -- (using a stethoscope) a scratchy noise is heard over the chest, as the two layers of the pericardium rub against each other.
5. Listening to the lower back, the doctor may hear Fluid in the Lungs (rales).
6. Pulse rate may speed up and then normalize.
7. Fever may be detected.

* Pericardial Tamponade:

1. All the same signs or symptoms as with acute Pericarditis
2. Patient is pale or with bluish lips (cyanosis)
3. Weak or absent pulse
4. Rapid, thready pulse rate
5. Low or no blood pressure (BP)
6. There may be >10 mm Hg drop in systolic BP (the number on top when BP is measured) when the patient breaths in (pulsus paradoxus).
7. Putting his hands over the heart, the doctor may feel little activity.
8. Lungs may be clear when listened to.
9. There may be friction rub.
10. There may be muffled or distant heart sounds, Low BP, and distended neck veins (jugular veins) known as Beck's triad.

* Constrictive Pericarditis:

1. Often a history of acute Pericarditis or viral illness
2. Shortness of breath (dyspnea)
3. Fatigue.
4. Listening to the lungs one may hear rales.
5. Listening to the heart, one may hear an abnormal sound known as a knock.
6. Swollen ankles, legs, arms, and abdomen
7. Distended jugular veins
8. Kussmaul's sign -- upon inspiration, the pressure in the jugular veins increase and distend the veins.

o Tests:

1. Blood samples -- show an increase in white blood cells and ESR, due to inflammation.
2. Heart chemicals (enzymes) can also be elevated (i.e., CK, LDH) in the blood. Liver enzymes may be elevated if there is right-sided Heart Failure.
3. Electrocardiogram or EKG -- (recording of electrical activities of the heart) in Pericarditis has a characteristic pattern.
4. Echocardiograph (echo) - uses sound waves to show a picture of the heart and pericardium. Echo can show if fluid is present. Using echo, a cardiologist can insert a needle in between the pericardial layers, and draw out a small amount of fluid (percardiocentesis), or take a small piece of pericardium (pericardial biopsy). The fluid or sample is then sent to a laboratory, where its contents and source are identified.
5. Cardiac catheterization (CC) -- uses a long wire inserted through the thigh vein and guided to the heart, in order to measure pressure changes inside the heart.
6. CC is useful when constrictive or tamponade Pericarditis is compressing the heart.
7. Chest CAT scan and MRI can provide detailed and clear pictures of the heart, such as the presence of a thick and calcified (Calcium deposits) pericardium in the case of chronic or constrictive Pericarditis.

RISK FACTORS
* See causes
* Chest Trauma -- open-heart surgery (postpericardiotomy) and stabbing may cause constrictive Pericarditis
* Men > Women
* Age -- adolescents and young men
* Upper respiratory infections -- colds

TREATMENT
* Mild cases -- outpatient treatment:

1. Rest
2. Aspirin or other nonsteroidal anti-inflammatory drugs (i.e., NSAIDS such as Motrin, Indocin, etc.) for 2 weeks. Side effects include stomach upset, bleeding, and others.
3. Prednisone pills for 2-4 weeks can also be used to reduce inflammation of the pericardium. Side effects include stomach ulcers and infections. This medicine cannot be stopped suddenly, but must be tapered.
4. Azothioprine and Phenylbutazone are also used in some cases, but have many side effects.

* In-patient therapy is recommended if there are signs of heart problems (shock, Low Blood Pressure, very irregular or rapid heart beat):

1. Monitor patient with serial EKG
2. Drain fluids as soon as possible

* If medication and fluid drainage is not effective, or in cases of severe constrictive Pericarditis with Heart Failure, a cardiac surgeon may be called in to remove the pericardium (pericardiectomy).

IF YOU SUSPECT THIS CONDITION
* See a doctor immediately. Call 911 if there is any pressure or pain in the chest, sweating or shortness of breath.

SIMILIAR CONDITIONS
* Heart attack
* Pneumonia -- lung infection
* Pleurisy -- inflammation of the sac covering the lung
* Pancreatitis -- inflammation of the pancreas
* Pulmonary Emboli -- blood clot in the lung
* Cholecystitis -- inflammation of the gallbladder



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