Thursday April 26 th, 2012

*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%)

 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

 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

 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 2 nd and 4 th intercostal space at LSB midclavicular line

 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

A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. OOf the following, the MOST likely expected finding on ECG is: AA. elevation of S-T segment BB. first-degree heart block CC. pre-excitation with a delta wave DD. tall peaked T waves EE. T-wave flattening

 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

 Usually normal  If effusion present, then triangular shaped heart with smooth border “Water-bottle” heart

 May be normal  May reveal effusion  Absence of effusion does not exclude pericarditis

 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

 Recurrence (30%)  Constrictive pericarditis  Cardiac tamponade

Noon Conference with Lunch