PERICARDIAL PERICARDIAL DISEASESDISEASES

PROF.DR. FERDA ÖZKANPROF.DR. FERDA ÖZKAN

To learn the structure of pericardiumTo learn the structure of pericardium To learn the types of pericardial To learn the types of pericardial

effusionseffusions To learn the types of pericarditisTo learn the types of pericarditis

The pericardium is comprised of The pericardium is comprised of the parietal pericardium (an the parietal pericardium (an outer fibrous layer) and the outer fibrous layer) and the visceral pericardium (an inner visceral pericardium (an inner serous membrane made of a serous membrane made of a single layer of mesothelial cells). single layer of mesothelial cells).

The visceral pericardium is The visceral pericardium is attached to the epicardial fat and attached to the epicardial fat and reflects back on itself to form the reflects back on itself to form the parietal pericardium. parietal pericardium.

Pericardial physiology includes 3 Pericardial physiology includes 3 main functions.main functions.• First,First, mechanical functionmechanical function, the , the

pericardium pericardium promotes cardiac efficiency promotes cardiac efficiency by limiting acute dilation,by limiting acute dilation, maintaining maintaining ventricular compliance with ventricular compliance with preservation of the Starling curve, and preservation of the Starling curve, and distributing hydrostatic forces. distributing hydrostatic forces. It also creates a closed chamber with It also creates a closed chamber with

subatmospheric pressure that aids atrial subatmospheric pressure that aids atrial filling and lowers transmural cardiac filling and lowers transmural cardiac pressures. pressures.

•Second,Second, membranous function:membranous function: -shields the heart by reducing -shields the heart by reducing external friction and acting as a external friction and acting as a barrier against extension of barrier against extension of infection and malignancy. infection and malignancy.

•Third,Third, ligamentous function: ligamentous function:

-the pericardium fixes the heart -the pericardium fixes the heart anatomically. anatomically.

Pericardial lesionsPericardial lesions

Pericardial lesions are almost always Pericardial lesions are almost always associated with disease in other portions associated with disease in other portions of the heart or surrounding structures or of the heart or surrounding structures or secondary to a systemic disorder; secondary to a systemic disorder; isolated isolated pericardial disease is unusual. pericardial disease is unusual.

Despite the large number of etiologies of Despite the large number of etiologies of pericardial disease, there are relatively pericardial disease, there are relatively few anatomic forms of pericardial few anatomic forms of pericardial involvement.involvement.

Pericardial EffusionPericardial Effusion Normally there is about Normally there is about 30 to 50 ml30 to 50 ml of of

thin, clear, straw-colored, translucent thin, clear, straw-colored, translucent fluid in the pericardial space. fluid in the pericardial space.

Under a variety of circumstances, Under a variety of circumstances, pericardial effusions may appearpericardial effusions may appear

An effusionAn effusion accumulate accumulatess slowly and slowly and isis rarely larger than 500 mlrarely larger than 500 ml

Rarely a large volume or rapid Rarely a large volume or rapid accumulation of a lesser volume may accumulation of a lesser volume may embarrass diastolic filling of the heart.embarrass diastolic filling of the heart.

Serous effusionSerous effusion ((in cardiac failurein cardiac failure)) tthe fluid is completely clear, or straw colored, he fluid is completely clear, or straw colored,

andand sterile; the serosal surfaces remain sterile; the serosal surfaces remain smooth. smooth.

SerosanguineousSerosanguineous ((in blunt chest trauma) in blunt chest trauma) CChylous effusionshylous effusions (in (in lymphatic lymphatic

obstructionobstruction))• contain lipid dropletscontain lipid droplets• benign or malignant mediastinal neoplasmsbenign or malignant mediastinal neoplasms..

The pericardium normally The pericardium normally contains as much as contains as much as 50 mL50 mL of an ultrafiltrate of plasma. of an ultrafiltrate of plasma.

Drainage occurs via the Drainage occurs via the thoracic duct and the right thoracic duct and the right lymphatic duct into the right lymphatic duct into the right pleural space. pleural space.

HemopericardiumHemopericardium Hemopericardium is the accumulation of Hemopericardium is the accumulation of

purepure blood in the pericardial sac blood in the pericardial sac ((distinct from distinct from hemorrhagic pericarditis, a condition in which there is an hemorrhagic pericarditis, a condition in which there is an

inflammatory exudate containing blood mixed with pusinflammatory exudate containing blood mixed with pus)).. Hemopericardium is almost invariably Hemopericardium is almost invariably

due to rupture of the heart wall due to rupture of the heart wall secondary to secondary to • myocardial infarction, myocardial infarction, • traumatic perforation, or rupture of the traumatic perforation, or rupture of the

intrapericardial aorta. intrapericardial aorta.

BBlood rapidly fills the sac under lood rapidly fills the sac under greatly increased pressure greatly increased pressure

PProducing cardiac tamponade roducing cardiac tamponade

Small amounts of blood may Small amounts of blood may result from the trauma sustained result from the trauma sustained during cardiopulmonary during cardiopulmonary resuscitationresuscitation..

PericarditisPericarditis   Inflammations of the pericardium are Inflammations of the pericardium are

usually secondary to a variety of usually secondary to a variety of • cardiac diseases, cardiac diseases, • to systemic disorders, or to systemic disorders, or • to metastases from neoplasms arising in to metastases from neoplasms arising in

remote sites. remote sites. Primary pericarditis is unusual and Primary pericarditis is unusual and

almost always of almost always of viral originviral origin.. The various etiologies usually evoke an The various etiologies usually evoke an

acute pericarditis, acute pericarditis, TTuberculosis and fungi produce chronic uberculosis and fungi produce chronic

reactions.reactions.

Acute PericarditisAcute Pericarditis

Acute pericarditis is an inflammation of the Acute pericarditis is an inflammation of the pericardium characterized by pericardium characterized by chest pain,chest pain, pericardial friction rub, and serial pericardial friction rub, and serial electrocardiographic changes. electrocardiographic changes.

ClassificationClassification (Pathology): (Pathology):• Serous Pericarditis Serous Pericarditis • Fibrinous and Serofibrinous Pericarditis Fibrinous and Serofibrinous Pericarditis • Purulent or Suppurative Pericarditis Purulent or Suppurative Pericarditis • Hemorrhagic Pericarditis Hemorrhagic Pericarditis • GranulomatousGranulomatous Pericarditis Pericarditis..

EtiologyEtiology

BacterialBacterial • 1-8% of cases and causes purulent 1-8% of cases and causes purulent

pericarditis. pericarditis. • Direct extension: Direct extension:

pulmonary extension, myocardial pulmonary extension, myocardial abscess/endocarditis, penetrating injury to abscess/endocarditis, penetrating injury to chest wall from either trauma or surgery, chest wall from either trauma or surgery, subdiaphragmatic suppurative lesion. subdiaphragmatic suppurative lesion.

• Hematogenous spread :Hematogenous spread : bacteriemia, sepsis, pyemiabacteriemia, sepsis, pyemia

• Organisms:Organisms: Gram-positiveGram-positive species species such as such as Streptococcus Streptococcus

pneumoniaepneumoniae and other and other StreptococcusStreptococcus species, species, StaphylococcusStaphylococcus, and , and gram-negativegram-negative species,species, including including Proteus, Escherichia coli, Proteus, Escherichia coli, Pseudomonas, Klebsiella, Salmonella, Pseudomonas, Klebsiella, Salmonella, Shigella, Neisseria meningitidisShigella, Neisseria meningitidis, and , and Haemophilus influenzaeHaemophilus influenzae. .

Less common organisms include Less common organisms include Legionella, Legionella, NocardiaNocardia, and , and Actinobacillus, RickettsiaActinobacillus, Rickettsia and and Lyme borreliosis (Lyme borreliosis (Borrelia burgdorferiBorrelia burgdorferi). ).

AnaerobesAnaerobes also have been isolated in also have been isolated in 40%40% of of patients in reviews of the pediatric patients in reviews of the pediatric population. population.

TuberculosisTuberculosis This accounts for 4% of cases. This accounts for 4% of cases. Especially in high-risk groups such as Especially in high-risk groups such as elderly patients in nursing homes. elderly patients in nursing homes.

Elevated adenosine deaminase in Elevated adenosine deaminase in pericardial fluid is useful for pericardial fluid is useful for diagnosing tuberculosis. diagnosing tuberculosis.

High adenosine deaminase values High adenosine deaminase values may indicate a poorer prognosis. may indicate a poorer prognosis.

Approximately half the patients Approximately half the patients develop constrictive pericarditis. develop constrictive pericarditis.

ViralViral • 1-10% of cases.1-10% of cases.• Causative viruses include coxsackievirus B, Causative viruses include coxsackievirus B,

echovirus, adenoviruses, influenza A and B echovirus, adenoviruses, influenza A and B viruses, Enterovirus, mumps virus, Epstein-viruses, Enterovirus, mumps virus, Epstein-Barr virus, human immunodeficiency virus Barr virus, human immunodeficiency virus (HIV), herpes simplex virus type 1, varicella (HIV), herpes simplex virus type 1, varicella zoster virus, measles virus, parainfluenza 2 zoster virus, measles virus, parainfluenza 2 virus, and respiratory syncytial virus. virus, and respiratory syncytial virus.

• Viruses, especially coxsackie B and influenza, Viruses, especially coxsackie B and influenza, can occur as seasonal epidemics. can occur as seasonal epidemics.

• It usually is a short self-limited disease lasting It usually is a short self-limited disease lasting 1-3 weeks. 1-3 weeks.

• Patients may have associated myocarditisPatients may have associated myocarditis. .

• HIV:HIV: Pericardial involvement is frequent, but Pericardial involvement is frequent, but

it usually is an asymptomatic pericardial it usually is an asymptomatic pericardial effusion of small volume.effusion of small volume.

It is found more frequently in advanced It is found more frequently in advanced HIV infection, with one study noting HIV infection, with one study noting right atrial diastolic compression in 5% right atrial diastolic compression in 5% of cases. Symptomatic pericarditis is of cases. Symptomatic pericarditis is observed in less than 1%. observed in less than 1%.

Etiology can include usual causes, Etiology can include usual causes, opportunistic infection, Kaposi sarcoma, opportunistic infection, Kaposi sarcoma, and HIV virus.and HIV virus.

Other infectious agents include the Other infectious agents include the following: following: • Fungal organisms include Fungal organisms include Histoplasma, Histoplasma,

Blastomyces, Coccidioides, AspergillusBlastomyces, Coccidioides, Aspergillus, and , and CandidaCandida. .

• Parasitic organisms include Parasitic organisms include Entamoeba, Entamoeba, EchinococcusEchinococcus, and , and Toxoplasma.Toxoplasma.

Idiopathic Idiopathic • Between 26% and 86% of cases are idiopathic Between 26% and 86% of cases are idiopathic

in nature. in nature. • No clinical features distinguish these from viral No clinical features distinguish these from viral

pericarditis. pericarditis. • Most likely, the majority of idiopathic cases are Most likely, the majority of idiopathic cases are

undiagnosed viral infections. undiagnosed viral infections. • Seasonal peaks occur in spring and fall.Seasonal peaks occur in spring and fall.

Rheumatoid arthritisRheumatoid arthritis • Autopsy studies show incidence of 11-50% in patients Autopsy studies show incidence of 11-50% in patients

with rheumatoid arthritis (RA). with rheumatoid arthritis (RA). • Pericardial involvement usually is clinically silent. Pericardial involvement usually is clinically silent. • Diagnosis is suggested by serous or hemorrhagic --Diagnosis is suggested by serous or hemorrhagic --

pericardial fluid with a glucose level of less than 45 pericardial fluid with a glucose level of less than 45 mg/dL,mg/dL,

-white blood cell count higher than 15,000/mm2 with -white blood cell count higher than 15,000/mm2 with

-cytoplasmic inclusion bodies, -cytoplasmic inclusion bodies,

-protein level higher than 5 g/dL, -protein level higher than 5 g/dL,

-low total serum hemolytic complement (CH50), -low total serum hemolytic complement (CH50),

-high immunoglobulin G (IgG) level, and -high immunoglobulin G (IgG) level, and

-high rheumatoid factor.-high rheumatoid factor.

-Cholesterol levels may be high in the fluid of patients -Cholesterol levels may be high in the fluid of patients with RA who have nodules.with RA who have nodules.

Systemic lupus erythematosus Systemic lupus erythematosus • 25% of patients with lupus. 25% of patients with lupus. • Autopsy series reveal pericardial involvement Autopsy series reveal pericardial involvement

in 62%. in 62%. • Fluid analysis reveals Fluid analysis reveals

--increased leukocytes of (PMN) increased leukocytes of (PMN) - high protein, high protein, - low-to-normal glucose, low-to-normal glucose, - low complement, and possibly a low complement, and possibly a - pH of less than 7pH of less than 7. . - Also, it will have positive autoantibodies, such Also, it will have positive autoantibodies, such

as the antinuclear antibody or anti–double-as the antinuclear antibody or anti–double-stranded DNA.. stranded DNA..

• Development of tamponade and constrictive Development of tamponade and constrictive pericarditis is rare.pericarditis is rare.

Scleroderma Scleroderma • 5-10% of patients with scleroderma.5-10% of patients with scleroderma.• Autopsy incidence rate is 70%. Autopsy incidence rate is 70%. • Pericardial effusions are observed in Pericardial effusions are observed in

40% of patients and can be due to 40% of patients and can be due to scleroderma, myocardial failure scleroderma, myocardial failure (restrictive cardiomyopathy), and (restrictive cardiomyopathy), and renal failure. renal failure.

• Restrictive cardiomyopathy and Restrictive cardiomyopathy and pericardial constriction can coexist. pericardial constriction can coexist.

• Usually, pulmonary hypertension, right Usually, pulmonary hypertension, right heart failure, and systolic dysfunction heart failure, and systolic dysfunction are observed. are observed.

• These patients have a poor prognosis.These patients have a poor prognosis.

Rheumatic feverRheumatic fever • It often accompanies endocarditis It often accompanies endocarditis

and myocarditis, with a worse and myocarditis, with a worse prognosis. prognosis.

• In adults, pericarditis may not In adults, pericarditis may not occur with myocardial or valvular occur with myocardial or valvular involvement, and it is associated involvement, and it is associated with a better prognosis.with a better prognosis.

• Antistreptolysin O titer usually is Antistreptolysin O titer usually is greater than 400. greater than 400.

• Rarely is a large effusion present. Rarely is a large effusion present.

SarcoidosisSarcoidosis •Pericarditis is present in Pericarditis is present in

autopsies of approximately autopsies of approximately 25% of these patients. 25% of these patients.

•Patients may not have Patients may not have significant myocardial significant myocardial infiltration. infiltration.

•It rarely causes cardiac It rarely causes cardiac tamponade or constrictive tamponade or constrictive pericarditis.pericarditis.

Pericarditis is described in other Pericarditis is described in other inflammatory conditions, including the inflammatory conditions, including the following:following: • Sjögren syndrome Sjögren syndrome • Mixed connective tissue disease Mixed connective tissue disease • Reiter syndrome Reiter syndrome • Ankylosing spondylitis Ankylosing spondylitis • Inflammatory bowel disease Inflammatory bowel disease • Wegener granulomatosis Wegener granulomatosis • Vasculitis, such as giant cell arteritis and Vasculitis, such as giant cell arteritis and

polyarteritis polyarteritis • Polymyositis Polymyositis • Behçet syndrome Behçet syndrome • Whipple disease Whipple disease • Familial Mediterranean fever Familial Mediterranean fever • Serum sicknessSerum sickness

Renal failure Renal failure • Renal failure accounts for approximately 12% Renal failure accounts for approximately 12%

of cases. of cases. • In the predialysis era, pericarditis developed In the predialysis era, pericarditis developed

in 35-50% of patients with uremia who had in 35-50% of patients with uremia who had chronic renal failure and less commonly in chronic renal failure and less commonly in those with acute renal failurethose with acute renal failure. .

• Death often followed in several weeks. Death often followed in several weeks. • With dialysis, the incidence rate is less than With dialysis, the incidence rate is less than

10%. 10%. Pericarditis occurs after the onset of dialysis Pericarditis occurs after the onset of dialysis in 8-in 8-

12%.12%. Some authors suggest that Some authors suggest that uremic pericarditisuremic pericarditis is a is a

different entity from different entity from dialysis-associated pericarditis.dialysis-associated pericarditis. Asymptomatic pericardial effusions can occur in 36-Asymptomatic pericardial effusions can occur in 36-

62% of patients with uremia who require dialysis. 62% of patients with uremia who require dialysis. The presence of a large pericardial effusion that The presence of a large pericardial effusion that

persists for longer than 10 days after intensive persists for longer than 10 days after intensive dialysis has a high likelihood of causing tamponade. dialysis has a high likelihood of causing tamponade.

Treatment is intensive dialysis. Treatment is intensive dialysis.

Hypothyroidism Hypothyroidism • 4% of cases. 4% of cases. • Pericardial involvement usually is Pericardial involvement usually is

observed with severe hypothyroidism. observed with severe hypothyroidism. • Patients may develop large pericardial Patients may develop large pericardial

effusions, but rarely do they develop effusions, but rarely do they develop tamponade. tamponade.

• Pericardial fluid often is clear with high Pericardial fluid often is clear with high protein and cholesterol levels and few protein and cholesterol levels and few cells. cells.

• Myocardial involvement is common.Myocardial involvement is common.

Cholesterol pericarditisCholesterol pericarditis •This also is called gold-paint This also is called gold-paint

pericarditis. pericarditis. •Granulomatous pericarditis has Granulomatous pericarditis has

been implicated in some cases. been implicated in some cases. •Development of constriction is Development of constriction is

rare.rare.

Myocardial infarctionMyocardial infarction • After a transmural infarction, a fibrinous pericardial After a transmural infarction, a fibrinous pericardial

exudate appears within 24 hours. It begins to exudate appears within 24 hours. It begins to organize at 4-8 days, and it completes organization organize at 4-8 days, and it completes organization at 4 weeks. at 4 weeks.

• Prior to thrombolytic therapy, infarct-associated Prior to thrombolytic therapy, infarct-associated pericarditis ranges from 7-23%. pericarditis ranges from 7-23%. At autopsy, almost all patients were noted to have localized At autopsy, almost all patients were noted to have localized

fibrinous pericarditis overlying the area of infarction. fibrinous pericarditis overlying the area of infarction. • With thrombolytic therapy and direct infarct With thrombolytic therapy and direct infarct

angioplasty, the incidence of infarct-associated angioplasty, the incidence of infarct-associated pericarditis has decreased to 5-8%. pericarditis has decreased to 5-8%.

• Overall, pericardial involvement indicates larger Overall, pericardial involvement indicates larger infarction, greater incidence of left ventricular infarction, greater incidence of left ventricular dysfunction, and greater mortality. dysfunction, and greater mortality.

• Pericarditis usually heals without consequence. Pericarditis usually heals without consequence. • Effusions may occur, but they rarely lead to Effusions may occur, but they rarely lead to

tamponade. tamponade.

Dressler syndromeDressler syndrome• Pericarditis associated with Dressler Pericarditis associated with Dressler

syndrome usually is observed syndrome usually is observed 2-3 weeks2-3 weeks after after a myocardial infarction. a myocardial infarction.

• It may be It may be a unique autoimmune-mediated a unique autoimmune-mediated phenomenon to myocardial antigens,phenomenon to myocardial antigens, or it or it may merely be an may merely be an unrecognized unrecognized postmyocardial infarction pericarditis.postmyocardial infarction pericarditis.

• Patients may develop pulmonary infiltrates Patients may develop pulmonary infiltrates and large pericardial effusions. and large pericardial effusions.

• Because of the risk of hemorrhagic Because of the risk of hemorrhagic pericarditis, anticoagulant therapy should be pericarditis, anticoagulant therapy should be stopped.stopped.

Postpericardiotomy syndromePostpericardiotomy syndrome • This is similar to Dressler syndrome, except it This is similar to Dressler syndrome, except it

occurs after cardiac surgery. occurs after cardiac surgery. • Several series note an incidence rate of 10-Several series note an incidence rate of 10-

40%. 40%. • Approximately 1% develop tamponade. Approximately 1% develop tamponade. • Pericardial effusions can occur in the absence of Pericardial effusions can occur in the absence of

typical features of postpericardiotomy typical features of postpericardiotomy syndrome. syndrome.

• The effusions were more common after heavy The effusions were more common after heavy postoperative bleeding. postoperative bleeding.

• Pericarditis is observed with other cardiac Pericarditis is observed with other cardiac instrumentation, including percutaneous instrumentation, including percutaneous transluminal coronary angioplasty (PTCA) and transluminal coronary angioplasty (PTCA) and pacemaker implantation. pacemaker implantation. Usually, it is associated with epicardial/pericardial Usually, it is associated with epicardial/pericardial

hematoma formation. hematoma formation.

NeoplasmNeoplasm • 5-17 % of cases. 5-17 % of cases. • Neoplastic disease, particularly advanced, is Neoplastic disease, particularly advanced, is

the most frequent cause of tamponade in the the most frequent cause of tamponade in the hospital. hospital.

• Occasionally, the tumor encases the heart Occasionally, the tumor encases the heart and causes constrictive pericarditis rather and causes constrictive pericarditis rather than tamponade. than tamponade.

• Primary neoplasm of the heart and Primary neoplasm of the heart and pericardium are rare. pericardium are rare. Pericardial mesothelioma and Pericardial mesothelioma and

angiosarcoma are lethal malignancies angiosarcoma are lethal malignancies with aggressive local spread that with aggressive local spread that respond poorly to treatment. Infants respond poorly to treatment. Infants and children can present with a and children can present with a teratoma in the pericardial space. teratoma in the pericardial space. These often can be removed These often can be removed successfully. successfully.

• Most cases occur as a result of Most cases occur as a result of metastatic disease. metastatic disease.

Autopsy studies have noted that Autopsy studies have noted that approximately approximately 10%10% of patient with of patient with cancer, develop cardiac cancer, develop cardiac involvement, and often, it is involvement, and often, it is clinically silent. clinically silent.

The neoplastic cells reach theThe neoplastic cells reach the

pericardium through the pericardium through the

bloodstream via lymphaticbloodstream via lymphatic

system, or local growth.system, or local growth.

• Metastatic tumors:Metastatic tumors: Lung cancer, including adenocarcinoma, Lung cancer, including adenocarcinoma,

squamous cell, and small cell, accounts squamous cell, and small cell, accounts for approximately for approximately 33%33% of cases. of cases.

Breast cancer accounts for 25%. Breast cancer accounts for 25%. Leukemia and lymphoma, including Leukemia and lymphoma, including

Hodgkin and non-Hodgkin, account for Hodgkin and non-Hodgkin, account for 15% of cases. 15% of cases.

Malignant melanoma represents Malignant melanoma represents another 5%. another 5%.

Kaposi sarcoma with the AIDS. Kaposi sarcoma with the AIDS. • The pericardial carcinoembryonic antigen The pericardial carcinoembryonic antigen

(CEA)(CEA) level often is elevated. level often is elevated.

•Cytology is positiveCytology is positive in 80-90% in 80-90% of of breastbreast and and lung cancer caseslung cancer cases, , but the percentage is lower in but the percentage is lower in other malignancies. Obstruction other malignancies. Obstruction of the lymphatic drainage can of the lymphatic drainage can cause the pericardial effusion to cause the pericardial effusion to be more significant than the be more significant than the tumor mass. tumor mass.

IrradiationIrradiation •Pericardial disease is the most Pericardial disease is the most

common cardiac toxicity.common cardiac toxicity. •High incidence is observed High incidence is observed

with high doses, especially with high doses, especially greater than 4000 rad. greater than 4000 rad.

•It can present as acute It can present as acute pericarditis, with or without pericarditis, with or without effusion; chronic constrictive effusion; chronic constrictive pericarditis; or effusive-pericarditis; or effusive-constrictive pericarditis.constrictive pericarditis.

Drugs Drugs

• Some medications, including penicillin and Some medications, including penicillin and cromolyn sodium, induce pericarditis through cromolyn sodium, induce pericarditis through a hypersensitivity reaction. a hypersensitivity reaction.

• The anthracycline antineoplastic agents, such The anthracycline antineoplastic agents, such as as doxorubicin doxorubicin and and cyclophosphamide,cyclophosphamide, have have direct direct cardiac toxicitycardiac toxicity and can cause acute and can cause acute pericarditis and myocarditis. pericarditis and myocarditis.

• Pericarditis can develop from a drug-induced Pericarditis can develop from a drug-induced SLE syndrome from medications, including SLE syndrome from medications, including procainamide, hydralazine, methyldopa, procainamide, hydralazine, methyldopa, isoniazid, mesalazine, and reserpine. isoniazid, mesalazine, and reserpine.

• Methysergide causes constrictive pericarditis Methysergide causes constrictive pericarditis through mediastinal fibrosis. through mediastinal fibrosis.

• Dantrolene, phenytoin, and minoxidil produce Dantrolene, phenytoin, and minoxidil produce pericarditis through an unknown mechanism. pericarditis through an unknown mechanism.

Serous PericarditisSerous Pericarditis   Serous inflammatory exudates are Serous inflammatory exudates are

characteristically produced by characteristically produced by noninfectious inflammations, such as noninfectious inflammations, such as RF RF systemic lupus erythematosus, systemic lupus erythematosus, scleroderma, tumors, and uremia.scleroderma, tumors, and uremia., ,

In some instances, a well-defined viral In some instances, a well-defined viral infection elsewhereinfection elsewhere –upper respiratory –upper respiratory tract, pneumonia, parotitis–tract, pneumonia, parotitis– antedates antedates the pericarditis and serves as the the pericarditis and serves as the primary focus of infection. primary focus of infection.

Serous PericarditisSerous Pericarditis This diagram depicts the This diagram depicts the

appearance of a serous appearance of a serous pericarditis. The amount of pericarditis. The amount of inflammation is minimal, inflammation is minimal, so no exudation of fibrin so no exudation of fibrin occurs. The dark stippled occurs. The dark stippled dots in the yellow fluid and dots in the yellow fluid and on the epicardial surface on the epicardial surface represent scattered represent scattered inflammatory cells. Serous inflammatory cells. Serous pericarditis is marked by pericarditis is marked by fluid collection. Rarely, the fluid collection. Rarely, the fluid collection may be fluid collection may be large enough to cause large enough to cause tamponade.tamponade.

Fibrinous and Serofibrinous PericarditisFibrinous and Serofibrinous Pericarditis MMost frequent type of pericarditisost frequent type of pericarditis a more or less serous fluid mixed with a a more or less serous fluid mixed with a

fibrinous exudate. fibrinous exudate. Common causes include Common causes include

• acute myocardial infarction, acute myocardial infarction, • the postinfarction (Dressler’s) syndrome the postinfarction (Dressler’s) syndrome • uremia, uremia, • chest radiation, chest radiation, • RF, RF, • systemic lupus erythematosus,systemic lupus erythematosus,• ttraumarauma• cardiac surgerycardiac surgery• pneumonia.pneumonia.

Fibrinous PericarditisFibrinous Pericarditis

This diagram depicts This diagram depicts the appearance of a the appearance of a fibrinous pericarditis. fibrinous pericarditis. The red-pink squiggly The red-pink squiggly lines extending from lines extending from the epicardial surface the epicardial surface into the yellow fluid into the yellow fluid represent the strands represent the strands of fibrin. This type of of fibrin. This type of pericarditis is typical pericarditis is typical of of uremia with renal uremia with renal failurefailure, underlying , underlying myocardialmyocardial infarction,infarction, and acute and acute rheumatic rheumatic carditiscarditis

Fibrinous PericarditisFibrinous Pericarditis A window of adherent A window of adherent

pericardium has been pericardium has been opened to reveal the opened to reveal the surface of the heart. surface of the heart. There are thin strands There are thin strands of fibrinous exudate of fibrinous exudate that extend from the that extend from the epicardial surface to epicardial surface to the pericarial sac. This the pericarial sac. This is typical for a is typical for a fibrinous pericarditis fibrinous pericarditis

Fibrinous PericarditisFibrinous Pericarditis

This is an example This is an example of a fibrinous of a fibrinous pericarditis. The pericarditis. The surface appears surface appears roughened from roughened from the normal the normal glistening glistening appearance by the appearance by the strands of pink-tan strands of pink-tan fibrin. fibrin.

Fibrinous PericarditisFibrinous Pericarditis

The epicardial surface of The epicardial surface of the heart shows a shaggy the heart shows a shaggy fibrinous exudate. This is fibrinous exudate. This is another example of another example of fibrinous pericarditis. This fibrinous pericarditis. This appearance has often been appearance has often been called a called a "bread and butter""bread and butter" pericarditis, but you would pericarditis, but you would have to drop your buttered have to drop your buttered bread on the carpet to bread on the carpet to really get this effect. The really get this effect. The fibrin often results in the fibrin often results in the the finding on physical the finding on physical examination of a "friction examination of a "friction rub" as the strands of fibrin rub" as the strands of fibrin on epicardium and on epicardium and pericardium rub against pericardium rub against each other. each other.

TThe pericardial surface here shows strands of pink fibrin he pericardial surface here shows strands of pink fibrin extending outward. There is underlying inflammation. Eventually, extending outward. There is underlying inflammation. Eventually, the fibrin can be the fibrin can be oorganized and cleared, though sometimes rganized and cleared, though sometimes adhesions may remain.adhesions may remain.

Purulent or Suppurative PericarditisPurulent or Suppurative Pericarditis TThe invasion of the pericardial space by he invasion of the pericardial space by

infective organisms. infective organisms. TheThe routes of routes of organisms: organisms:

• (1)(1) direct extensiondirect extension from neighboring from neighboring inflammations, such as an empyema of the pleural inflammations, such as an empyema of the pleural cavity, lobar pneumonia, mediastinal infections, or cavity, lobar pneumonia, mediastinal infections, or extension of a ring abscess through the extension of a ring abscess through the myocardium or aortic root in myocardium or aortic root in infective endocarditisinfective endocarditis

• (2) seeding from the blood;(2) seeding from the blood; • (3) lymphatic extension;(3) lymphatic extension; • ((4) direct introduction during cardiotomy.4) direct introduction during cardiotomy.

Immunosuppressive therapy potentiates all of these Immunosuppressive therapy potentiates all of these pathways.pathways.

The exudate ranges from a thin to a The exudate ranges from a thin to a creamy pus of up to 400 to 500 ml in creamy pus of up to 400 to 500 ml in volume. volume.

The serosal surfaces are reddened, The serosal surfaces are reddened, granular, and coated with the exudate. granular, and coated with the exudate.

Microscopically there is an acute Microscopically there is an acute inflammatory reaction. inflammatory reaction.

Sometimes the inflammatory process Sometimes the inflammatory process extends into surrounding structures to extends into surrounding structures to induce a so-called induce a so-called mediastinopericarditis.mediastinopericarditis.

Acute purulent pericarditisAcute purulent pericarditis An exudate is an An exudate is an

inflammatory extravascular inflammatory extravascular fluid that has a specific fluid that has a specific gravity greater than 1.020 gravity greater than 1.020 and contains a large and contains a large amount of protein and amount of protein and cellular debris. This is an cellular debris. This is an example of an exudate that example of an exudate that is seen with pericarditis and is seen with pericarditis and is often called is often called bread and bread and butter pericarditisbutter pericarditis due to its due to its appearance. Purulent is appearance. Purulent is synonymous with synonymous with suppurative and implies a suppurative and implies a non-viral etiology. non-viral etiology.

This is a purulent pericarditis. Note the yellowish This is a purulent pericarditis. Note the yellowish exudate that has pooled in the lower pericardial exudate that has pooled in the lower pericardial sac seen been opened here.sac seen been opened here.

Etiology:Etiology:• A preexisting or concurrent infection such as A preexisting or concurrent infection such as

pneumonia with or without empyema, pneumonia with or without empyema, meningitis, osteomyelitis, arthritis, or other meningitis, osteomyelitis, arthritis, or other soft tissue infections.soft tissue infections.

• Patients recovering from thoracic, cardiac, or Patients recovering from thoracic, cardiac, or esophageal surgery are at risk for purulent esophageal surgery are at risk for purulent pericarditis.pericarditis.

• Purulent pericarditis has been reported in Purulent pericarditis has been reported in patients recovering from traumatic injury.patients recovering from traumatic injury.

• The organisms that most commonly cause The organisms that most commonly cause purulent pericarditis are purulent pericarditis are Staphylococcus Staphylococcus aureus, H influenzae, Neisseria meningitidis,aureus, H influenzae, Neisseria meningitidis, and and Streptococcus pneumoniae.Streptococcus pneumoniae. Less common organisms include gram-Less common organisms include gram-

negative enteric bacilli, negative enteric bacilli, Pseudomonas Pseudomonas aeruginosa, Salmonellaaeruginosa, Salmonella species, species, Francisella tularensis, and anaerobic Francisella tularensis, and anaerobic bacteria and fungi (bacteria and fungi (HistoplasmaHistoplasma species, species, coccidioidomycosis, blastomycosis, coccidioidomycosis, blastomycosis, AspergillusAspergillus species, species, CandidaCandida species). species).

S. aureusS. aureus• This is the This is the most common organism in most common organism in

children,children, causing approximately 40% of causing approximately 40% of cases.cases.

• Pericarditis occurs concomitantly with Pericarditis occurs concomitantly with pneumonia with empyema and less pneumonia with empyema and less often with acute osteomyelitis or soft often with acute osteomyelitis or soft tissue abscess. tissue abscess.

• Rarely, pericarditis is associated with Rarely, pericarditis is associated with S S aureusaureus endocarditis. endocarditis.

• Necrotizing infection and exotoxin Necrotizing infection and exotoxin production lead to increased incidence production lead to increased incidence of shock and higher mortality risk.of shock and higher mortality risk.

• Within the first 3 months after cardiac Within the first 3 months after cardiac surgery, surgery, S aureusS aureus is the most common is the most common cause of purulent pericarditis.cause of purulent pericarditis.

H. İnfluenzaeH. İnfluenzae

• This is the second most common This is the second most common organism listed in most reported organism listed in most reported pediatric case series of purulent pediatric case series of purulent pericarditis,pericarditis,

• Infection of the upper or lower Infection of the upper or lower respiratory tract frequently precedes respiratory tract frequently precedes pericarditis caused by pericarditis caused by H influenzae.H influenzae.

• Purulent pericarditis may occur with Purulent pericarditis may occur with H H influenzaeinfluenzae meningitis. meningitis.

• H influenzaeH influenzae produces very thick produces very thick fibrinopurulent exudate.fibrinopurulent exudate.

N. meningitidisN. meningitidis• Pericarditis occurs in approximately 5% of Pericarditis occurs in approximately 5% of

young adults with meningococcemia. young adults with meningococcemia. • The clinical course is often milder than with The clinical course is often milder than with

other causes of purulent pericarditis. other causes of purulent pericarditis. • Pericardial effusion can be detected at the Pericardial effusion can be detected at the

onset of the illness or later in the course of the onset of the illness or later in the course of the infection. infection.

S. pneumoniae:S. pneumoniae: • At one time, At one time, S pneumoniaeS pneumoniae was the leading was the leading

cause of purulent pericarditis, but it has cause of purulent pericarditis, but it has become much less common perhaps because become much less common perhaps because of widespread use of antibiotics.of widespread use of antibiotics.

Other organismsOther organisms• Gram-negative enteric bacilli and anaerobes Gram-negative enteric bacilli and anaerobes

or fungi, are rare but should be considered in or fungi, are rare but should be considered in patients who are immunocompromised. patients who are immunocompromised.

• AspergillusAspergillus pericarditis arises as a result of pericarditis arises as a result of pulmonary infection in patients who are pulmonary infection in patients who are immunocompromised. immunocompromised.

• Mycoplasma pneumoniaeMycoplasma pneumoniae pericarditis is pericarditis is associated with pulmonary disease.associated with pulmonary disease.

Complications: Complications: • Myocardial involvementMyocardial involvement• Heart failure Heart failure • Constrictive pericarditisConstrictive pericarditis

Constrictive pericarditis is a rare complication.Constrictive pericarditis is a rare complication. increased systemic venous pressure, increased systemic venous pressure,

hepatomegaly, dyspnea, and decreased urine hepatomegaly, dyspnea, and decreased urine output. output.

Hemorrhagic PericarditisHemorrhagic Pericarditis  

An exudate composed of blood An exudate composed of blood mixed with a fibrinous or suppurative mixed with a fibrinous or suppurative effusion is most commonly caused by effusion is most commonly caused by

tuberculosistuberculosis direct malignant neoplastic involvement direct malignant neoplastic involvement cardiac surgery.cardiac surgery.

The surface of the heart with hemorrhagic pericarditis The surface of the heart with hemorrhagic pericarditis demonstrates a roughened and red appearance. demonstrates a roughened and red appearance. Hemorrhagic pericarditis is most likely to occur with Hemorrhagic pericarditis is most likely to occur with metastatic tumor and with tuberculosis (TB). TB can also metastatic tumor and with tuberculosis (TB). TB can also lead to a granulomatous pericarditis that may calcify and lead to a granulomatous pericarditis that may calcify and produce a "constrictive" pericarditis.produce a "constrictive" pericarditis.

GranulomatGranulomatous Pericarditisous Pericarditis Tuberculosis, fungal infections, Tuberculosis, fungal infections,

rheumatoid arthritis, and sarcoidosis. rheumatoid arthritis, and sarcoidosis. Caseation within the pericardial sac isCaseation within the pericardial sac is

tuberculoustuberculous in origin in origin• IInfrequently nfrequently mycotic infectionsmycotic infections evoke a evoke a

similar pattern. similar pattern. • The pericardium is usually involved by The pericardium is usually involved by

direct spread from direct spread from tuberculous focituberculous foci within within the the tracheobronchial nodes.tracheobronchial nodes.

• Caseous pericarditisCaseous pericarditis is the most frequent is the most frequent antecedent of disabling, fibrocalcific, antecedent of disabling, fibrocalcific, chronic constrictive pericarditis.chronic constrictive pericarditis.

Chronic or Healed Pericarditis Chronic or Healed Pericarditis  OOrganization merely producesrganization merely produces

• plaque-like fibrous thickeningsplaque-like fibrous thickenings• thin, delicate adhesions thin, delicate adhesions ((rarely cause impairment of rarely cause impairment of

cardiac functioncardiac function)) • complete obliteration of the pericardial sac. complete obliteration of the pericardial sac.

This fibrosis yields a delicate, stringy type of This fibrosis yields a delicate, stringy type of adhesion between adhesion between parietal and visceral parietal and visceral pericardiumpericardium called called adhesive pericarditisadhesive pericarditis, which , which rarely hampers or restricts cardiac action. rarely hampers or restricts cardiac action.

In some cases, however, healed pericarditis can In some cases, however, healed pericarditis can be clinically important, especially when it takes be clinically important, especially when it takes the form of the form of adhesive mediastinopericarditis or adhesive mediastinopericarditis or constrictive pericarditis.constrictive pericarditis.

Adhesive MediastinopericarditisAdhesive Mediastinopericarditis May followMay follow::

• a suppurative or caseous pericarditis, a suppurative or caseous pericarditis, • previous cardiac surgery,previous cardiac surgery,• iirradiation to the mediastinum.rradiation to the mediastinum.

The pericardial sac is obliterated, and The pericardial sac is obliterated, and adherence of the external aspect of the adherence of the external aspect of the parietal layer to surrounding structures parietal layer to surrounding structures produces a great strain on cardiac produces a great strain on cardiac function. function.

The increased workload causes The increased workload causes cardiac cardiac hypertrophy and dilatationhypertrophy and dilatation,, which may which may be quite massive in more severe casesbe quite massive in more severe cases..

Constrictive PericarditisConstrictive Pericarditis The heart may be encased in a dense, fibrous, The heart may be encased in a dense, fibrous,

or fibrocalcific scar that limits diastolic or fibrocalcific scar that limits diastolic expansion and seriously restricts cardiac expansion and seriously restricts cardiac output. output.

HHistory of a previous suppurative, istory of a previous suppurative, hemorrhagic, or caseous (tuberculous) hemorrhagic, or caseous (tuberculous) pericarditis, but more often the cause is pericarditis, but more often the cause is uncertain. uncertain.

TThe pericardial space is obliterated, and the he pericardial space is obliterated, and the heart is surrounded by a dense, adherent heart is surrounded by a dense, adherent layer of scar or calcification, often 0.5 to 1.0 layer of scar or calcification, often 0.5 to 1.0 cm thick, that can resemble a plaster mold in cm thick, that can resemble a plaster mold in extreme cases extreme cases ((concretio cordis).concretio cordis).

Cardiac hypertrophy and dilatation Cardiac hypertrophy and dilatation cannotcannot occur because of the dense enclosing scar, occur because of the dense enclosing scar, and the heart is consequently quiet with and the heart is consequently quiet with reduced output. reduced output.

Etiology: Etiology: • Chronic constrictive pericarditis develops Chronic constrictive pericarditis develops

insidiously; frequently, an etiology is never insidiously; frequently, an etiology is never determined.determined.

• In some (approximately 10%) patients, an In some (approximately 10%) patients, an antecedent antecedent acute pericarditisacute pericarditis exists. exists. TuberculosisTuberculosis is the most frequent known cause of is the most frequent known cause of

chronic constrictive pericarditis. chronic constrictive pericarditis. Other causal organisms include (among others) Other causal organisms include (among others)

staphylococci, streptococci, and fungi such as staphylococci, streptococci, and fungi such as histoplasmosis.histoplasmosis.

Rheumatoid diseaseRheumatoid disease SarcoidosisSarcoidosis Mediastinal radiationMediastinal radiation Trauma (hemopericardium)Trauma (hemopericardium) Status post–cardiac surgery (postpericardiotomy Status post–cardiac surgery (postpericardiotomy

syndrome)syndrome) UremiaUremia Neoplastic diseaseNeoplastic disease Postinfectious (bacterial) pericarditisPostinfectious (bacterial) pericarditis Various metabolic and genetic disorders.Various metabolic and genetic disorders.

Pericardium in Pericardium in Rheumatoid arthritisRheumatoid arthritis

The heart is involved in 20 to 40% of cases of The heart is involved in 20 to 40% of cases of severe prolonged rheumatoid arthritis. severe prolonged rheumatoid arthritis.

FFibrinous pericarditisibrinous pericarditis (dense (dense fibrous adhesionsfibrous adhesions)) In the early stages of this process, rheumatoid In the early stages of this process, rheumatoid

inflammatory inflammatory granulomatous nodulesgranulomatous nodules resembling those resembling those that occur subcutaneously may be identifiable deep to that occur subcutaneously may be identifiable deep to the pericardial surfacesthe pericardial surfaces ( (rheumatoid nodules rheumatoid nodules may may involve the myocardium, endocardium, valves of the involve the myocardium, endocardium, valves of the heart, and root of the aortaheart, and root of the aorta)). .

Amyloid Amyloid involving the heart can also occur secondary involving the heart can also occur secondary to rheumatoid arthritis.to rheumatoid arthritis.

Thank youThank you