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					                                                                                   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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posted:11/15/2011
language:English
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