CARDIOLOGY—1 If pericarditis remains active for a week or more, a TB skin test is indicated and three samples of sputum or ACUTE PERICARDITIS gastric washings should be examined and cultured History for tuberculosis. TB pericarditis often progresses rapidly to effusive- 1) Chest pain constrictive or constrictive pericarditis. 2) Pleuritic PNA or pulmonary infarction. Diagnosis with PCR to identify TB in pericardial fluid, 3) Pericardial Characteristic radiation of pericardial and adenosine deaminase activity helps indicate the pain is to the shoulder (the trapezius ridge.) Pt finds probability of TB. relief by sitting up, and reports worsening of the Regrettably, a number of patients are treated on pain with inspiration. presumptive evidence such as a recent conversion of 4) Dysphagia sometimes accompanies pericardial pain. the skin test and known contact with the disease. 5) Fever AIDS presents a whole new subset of patients who 6) Pericardial friction rub (rub may come and go) may develop TB or other varieties of pericarditis Differential diagnosis because of their immunosuppression. 1) AMI Pericardiocentesis: 2) dissecting aorta Effusions should be drained. Cardiac tamponade is an 3) pulmonary embolism unequivocal indication for pericardiocentesis. If 4) number of thoracic and abdominal catastrophes pericarditis remains active or the effusion persists Causes for three or four weeks, pericardial biopsy should be Any clue on history, PE or routine labs suggesting a done. Pericardiocentesis is frequently followed systemic disorder as the cause of pericarditis must after several weeks by pericardiectomy because of be followed up. the likelihood that the patient has by that stage 1) Inflammatory illness flu-like illness and fever. developed effusive-constrictive pericarditis and to Sudden onset. Viral infection: Most common prevent chronic constrictive pericarditis. Whether etiology of acute pericarditis adding prednisone to the treatment of acute 2) Collagen vascular disorders tuberculosis pericarditis prevents subsequent 3) Drugs such as procainamide constriction. 4) Trauma or prior MI (Dressler’s syndrome) 5) Cardiac surgery (post-pericardiotomy syndrome) 6) Renal failure 7) Bacterial and other infections 8) Trauma and aortic dissection. 9) After radiation. Lab evaluation: electrolytes, BUN, CBC (leukocytosis), sed rate, CXR, and ECG. Do further testing only to follow specific clues, or when the clinical course is atypical. Echo: useful for confirming the diagnosis when it shows even a small pericardial effusion, but absence of effusion by no means excludes the diagnosis. Treatment Bed rest, symptomatic treatment of pain, and careful monitoring for development of hemodynamic compromise. NSAIDS indocin. Can use ibuprofen. In some pts cholchicine works well as monotherapy or as add on to NSAIDS. Steroids: Used only if required for a specific illness such as a connective tissue dz or as the last resort Recurrent Pericarditis One of the most difficult cardiac problems that internists may have to face. What at first appeared to be a simple case of idiopathic or viral acute pericarditis may, after apparent cure, recur on multiple occasions over a period of months or even years. The same phenomenon may follow acute effusive pericarditis, Dressler’s syndrome, post-traumatic pericarditis, and the post-pericardiotomy syndrome. Recurrences respond to prednisone, but because of its unwanted effects and because some patients become dependent on it, every effort should be made to avoid or minimize its use. Tuberculosis pericarditis: Uncommon in the United States. Does not have a characteristic clinical course. 5 % of pts w/apparent idiopathic pericarditis are subsequently found to have TB pericarditis TB must be considered a diagnostic possibility in all cases of pericarditis, acute or chronic. If pericarditis resolves within a week, either spontaneously or in response to simple anti- inflammatory treatment, tuberculosis is very unlikely. TB pericarditis may be dry or effusive at presentation.
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