Pericarditis: Diagnosis

by John Fisher, MD

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    00:01 In terms of making a specific diagnosis, we’ve got to find out what’s in the fluid. Now, if the patient is only mildly ill, you probably would not do a pericardiocentesis. But if the patient is substantially ill, you’ve got to get some of that fluid for stains and culture. Once again, you wouldn’t put a patient through such a procedure without getting the maximum yield from the procedure. So, simply to culture it for routine bacteria would hurt the patient. If you’re going to do such an invasive procedure, you’re going to do stains and cultures, I like to say for everything known to man, for routine, AFB, and fungi.

    00:51 While you’re at it, to rule out malignancy, you would want to get cytology on the fluid.

    00:58 The analysis of the pericardial fluid also checks the level of glucose, protein, LDH, cell count with differential and also serum compliment.

    01:06 Special tests can include tumor markers and PCR, for mycobacterium tuberculosis if TB is suspected.

    01:14 Sometimes when the fluid is substantial and a pericardial window must be placed to drain the fluid by the cardiac and chest surgeons, you want to go ahead and get a pericardial biopsy.

    01:30 because actually having a large amount of tissue increases the yield for determining the cause.

    01:37 So, pericardiectomy with biopsy and drainage when there’s need for doing an invasive procedure.

    01:48 It’s going to produce higher yield and fewer complications than sticking the pericardium.

    01:55 A specific diagnosis can generally be made in at least half the patients. Keep in mind that many of these are caused by viruses which we are unable to identify. So, how do you treat pericarditis? Well, if you’re pretty convinced that you’re talking about a viral problem, nonsteroidal anti-inflammatory drugs are given to relieve pain and decrease the inflammation. You only resort to corticosteroids if it’s refractory to that treatment. For bacterial pericarditis, obviously you have to find out what bacterium is causing it and target your antibiotics to stains and cultures. Bacterial pericarditis must be drained. With respect to tuberculosis, if you diagnose that, it’s 4-drug therapy per usual for active tuberculosis. But because of the likelihood of constrictive pericarditis, we add steroids to the treatment to prevent constriction. For cardiac tamponade, we certainly need to do pericardiocentesis emergently if it’s an emergent problem or put an intrapericardial catheter for one to two days for acute infectious pericarditis and then withdrawing the catheter should be able to do something with that.

    03:35 For healed pericarditis, you can get a plaque-like, fibrous thickening of the serosal surface, so called soldier’s plaque. That doesn’t usually have any effect on cardiac function. For the treatment of adhesive mediastinopericarditis, the pericardial sac is often completely obliterated.

    04:02 That could compromise cardiac contraction. For the treatment of constrictive pericarditis, this can produce a dense, fibrous or fibrocalcific scar. You can actually have calcium deposits in the pericardial sac. That will unquestionably limit diastolic filling. For this, a pericardiectomy is required. This requires painstaking surgery. Of course, that brings me to the end of my discussion of pericarditis. I hope it helped.

    About the Lecture

    The lecture Pericarditis: Diagnosis by John Fisher, MD is from the course Cardiovascular Infections. It contains the following chapters:

    • Pericarditis – Diagnosis
    • Pericarditis – Management

    Included Quiz Questions

    1. Bacterial and fungal stains and culture, AFB, and cytology.
    2. Bacterial stains and culture only.
    3. Bacterial and fungal stains and cultures only.
    4. AFB first, other tests if AFB comes back negative.
    5. Cell cytology first to determine if it is infectious or malignancy related prior to performing other tests.
    1. In the treatment of pericarditis due to tuberculosis.
    2. In the treatment of all forms of pericarditis.
    3. In the treatment of viral pericarditis.
    4. In the treatment of bacterial pericarditis.
    5. Only in the treatment of non-infectious pericarditis.
    1. Non-steroidal anti-inflammatory drugs.
    2. Corticosteroids
    3. Non-steroidal anti-inflammatory drugs in combination with corticosteroids.
    4. Antiretrovirals
    5. No medical treatment is indicated.
    1. Surgical pericardiectomy
    2. Percutaneous pericardiocentesis
    3. Long term antibiotic therapy
    4. Long term corticosteroid therapy
    5. Cardiac transplant

    Author of lecture Pericarditis: Diagnosis

     John Fisher, MD

    John Fisher, MD

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