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Thursday April 26 th , 2012. Good Morning!. Pericarditis. *Inflammatory condition that can arise from a wide variety of causes: Infection Autoimmune JIA, SLE Rheumatic fever Uremia Malignancy Reaction to a drug Post cardiac surgery Idiopathic (30%). *Viral infection.

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Good Morning!

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  1. Thursday April 26th, 2012 Good Morning!

  2. Pericarditis • *Inflammatory condition that can arise from a wide variety of causes: • Infection • Autoimmune • JIA, SLE • Rheumatic fever • Uremia • Malignancy • Reaction to a • drug • Post cardiac • surgery • Idiopathic (30%)

  3. *Viral infection • Most common cause • Prodrome of respiratory or GI illness • Coxackievirus • Echovirus • Adenovirus • EBV • Influenza • HIV • Presentation = fever, chest pain, friction rub • Often accompanied by myocarditis

  4. *Bacterial pericarditis • Less common, but higher mortality • Staph aureus • Haemophilus influenzae • Presentation = toxic appearance, high temp, irritable, chest pain, cardiomegaly • May be post-op or from another site (PNA) • TB pericarditis • Spread from lymph nodes or blood borne • Large effusions and cardiac tamponade common

  5. Clinical Manifestations • Chest pain tends to be substernal, sharp, worse with inspiration and relieved by sitting upright and leaning forward • Radiates to scapular ridge • Pericardial friction rub • Scratchy, high-pitched to-and-fro sound • Heard best in 2nd and 4th intercostal space at LSB midclavicular line

  6. *Lab Eval • Elevated WBC, ESR, and CRP • Troponin may be increased • Blood cx, viral cx, TB skin testing, gastric cultures for Mycobacterium, RF, and ANA may be helpful • ECG most useful diagnostic test

  7. Question • A 15-year-old patient is brought to your office with the complaint of chest pain. She had been healthy until 3 days ago, when she developed a fever. The pain is percordial, referred to the epigastrum, and exacerbated by deep breathing and coughing. She refuses to lie down and prefers to sit leaning forward. • Of the following, the MOST likely expected finding on ECG is: • A. elevation of S-T segment • B. first-degree heart block • C. pre-excitation with a delta wave • D. tall peaked T waves • E. T-wave flattening

  8. ECG • 4 stages • 1. Diffuse ST segment elevation and PR segment depression • 2. Normalization of the ST and PR segments • 3. Development of widespread T-wave inversions • 4. Normalization of the T-waves • If effusion is present → low-voltage QRS • If cardiac tamponade→ electrical alternans

  9. CXR • Usually normal • If effusion present, then triangular shaped heart with smooth border “Water-bottle” heart

  10. Echo • May be normal • May reveal effusion • Absence of effusion does not exclude pericarditis

  11. *Management • Treat the underlying cause • NSAIDS = to alleviate chest pain • If chest pain persists beyond 2 weeks, colchicine can be added • Steroids = reserved for those unresponsive to NSAIDS and colchicine or with a rheumatologic or recurrent disease • Pericardiocentesis = indicated with hemodynamic compromise, cardiac tamponade, purulent pericarditis, and suspected neoplastic pericarditis • Resistant cases→ pericardial window or pericardiectomy

  12. Complications • Recurrence (30%) • Constrictive pericarditis • Cardiac tamponade

  13. Bleeding DisordersDr. Gardner Noon Conference with Lunch

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