Pericarditis in bacterial diseases - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
Chest pain Sharp pain, worsen with inspiration,
worse when supine,improved when sitting up or leaning forward
Referred to the scapular ridge, presumably due to irritation of the phrenic nerves, which pass adjacent to the pericardium
Chest pain
Sharp pain, worsen with inspiration,
worse when supine,improved when sitting up or leaning forward
Referred to the scapular ridge, presumably due to irritation of the phrenic nerves, which pass adjacent to the pericardium
Shortness of breath Due to sharp chest pain which worsen with inspiration Shortness of breath
Due to sharp chest pain which worsen with inspiration
Fever Due to ongoing infection.Bacteria can spread through blood from another infection in the body, such as pneumonia Fever
Due to ongoing infection.Bacteria can spread through blood from another infection in the body, such as pneumonia
Recent history of heart surgery The causative organism can be introduced during the surgery Recent history of heart surgery
The causative organism can be introduced during the surgery
Recent history of chest trauma The causative organism can be introduced due to a trauma Recent history of chest trauma
The causative organism can be introduced due to a trauma
Cough Due to shortness of breath and anxiety.
Can also be due to a pneumonia which has given rise to the spread of the causative organism
Cough
Due to shortness of breath and anxiety.
Can also be due to a pneumonia which has given rise to the spread of the causative organism
Sweating Due to anxiety Sweating
Due to anxiety
Immunocompromised patients/ patients with HIV More prone to get bacterial pericarditis as the immune system does not function well to act against the causative agents Immunocompromised patients/ patients with HIV
More prone to get bacterial pericarditis as the immune system does not function well to act against the causative agents
History of chronic disease (eg: alcohol abuse, rheumatoid arthritis) More prone for infections History of chronic disease (eg: alcohol abuse, rheumatoid arthritis)
More prone for infections
History of tuberculosis/ chronic dry cough,loss of appetite,loss of weight Tuberculosis can give rise to pericarditis with the spread of the organism History of tuberculosis/ chronic dry cough,loss of appetite,loss of weight
Tuberculosis can give rise to pericarditis with the spread of the organism
Ankle swelling If the pericarditis is not identified and treat properly, it can give rise to complications such as heart faiure Ankle swelling
If the pericarditis is not identified and treat properly, it can give rise to complications such as heart faiure
Symptoms of systemic disease eg:skin rash Several types of bacteria which can give rise to systemic infections can cause bacterial pericarditis through hematigenous spread.(Pneumococci, Meningococci, Gonococci, Hemophilus, Treponema pallidum, Borreliosis, Chlamydia, Tuberculosis etc) Symptoms of systemic disease eg:skin rash
Several types of bacteria which can give rise to systemic infections can cause bacterial pericarditis through hematigenous spread.(Pneumococci, Meningococci, Gonococci, Hemophilus, Treponema pallidum, Borreliosis, Chlamydia, Tuberculosis etc)
Acutely ill and extremely toxic/confused patient Due to severe infection and pain.Patient may be in septic shock Acutely ill and extremely toxic/confused patient
Due to severe infection and pain.Patient may be in septic shock

Clinicals - Examination

Fact Explanation
Pericardial friction rub Due to fluid in between the pericardial layers.Scratchy superficial sound that is heard most strongly in the mesocardium and
the lower left parasternal edge and that varies in
strength with respiratory movements
Pericardial friction rub
Due to fluid in between the pericardial layers.Scratchy superficial sound that is heard most strongly in the mesocardium and
the lower left parasternal edge and that varies in
strength with respiratory movements
Dyspnea/ hyperventilation Pain leading to shortness of breath or may be due to an on going pneumonia.
systemic inflammatory response syndrome may be present due to severe infection which give rise to hyperventilation
Dyspnea/ hyperventilation
Pain leading to shortness of breath or may be due to an on going pneumonia.
systemic inflammatory response syndrome may be present due to severe infection which give rise to hyperventilation
Signs of septic shock-Tachycardia , low blood pressure,confused patient Severe systemic infection can lead to septic shock Signs of septic shock-Tachycardia , low blood pressure,confused patient
Severe systemic infection can lead to septic shock
Scar marks due to recent surgeries Organism may be introduced during surgery or chest trauma Scar marks due to recent surgeries
Organism may be introduced during surgery or chest trauma
Pulsus paradoxus ( abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration ) Due to cardiac tamponade.(Bacterial pericarditis can lead to cardiac tamponade) Pulsus paradoxus ( abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration )
Due to cardiac tamponade.(Bacterial pericarditis can lead to cardiac tamponade)
Beck's triad - low blood pressure (due to decreased cardiac output), muffled heart sounds and distension of the jugular vein Due to cardiac tamponade.(Bacterial pericarditis can lead to cardiac tamponade) Beck's triad - low blood pressure (due to decreased cardiac output), muffled heart sounds and distension of the jugular vein
Due to cardiac tamponade.(Bacterial pericarditis can lead to cardiac tamponade)
Patient in pain Chest pain is a feature of pericarditis and pressure over the sternum increases the chest pain Patient in pain
Chest pain is a feature of pericarditis and pressure over the sternum increases the chest pain
Wasted apparance Due to tuberculosis which can give rise to pericarditis Wasted apparance
Due to tuberculosis which can give rise to pericarditis
Skin rash Due to the primary infection.Several types of bacteria which can give rise to systemic infections can cause bacterial pericarditis through hematogenous spread.(Pneumococci, Meningococci, Gonococci, Haemophilus, Treponema pallidum, Borreliosis, Chlamydia, Tuberculosis etc) Skin rash
Due to the primary infection.Several types of bacteria which can give rise to systemic infections can cause bacterial pericarditis through hematogenous spread.(Pneumococci, Meningococci, Gonococci, Haemophilus, Treponema pallidum, Borreliosis, Chlamydia, Tuberculosis etc)
Ankle oedema , hepatomegaly If not properly treated, patients may go into heart failure Ankle oedema , hepatomegaly
If not properly treated, patients may go into heart failure

Investigations - Diagnosis

Fact Explanation
Electrocardiogram ST segment - widespread concave
Frequent PR segment depression.
Electrocardiogram
ST segment - widespread concave
Frequent PR segment depression.
Pericardial fluid analysis Percutaneous pericardiocentesis must be promptly performed. Obtained pericardial fluid should undergo urgent Gram, acid-fast staining.
Bacterial pericarditis-
Purulent fluid,high protein content,leukocyte >10000/ml,massive granulocytes and macrophages
Tuberculous pericarditis-
positive acid fast staining.Serosanguinous fluid, leukocyte >8000/ml,positive adenosine deaminase levels ( >40u/ml ),positive PCR analysis
Pericardial fluid analysis
Percutaneous pericardiocentesis must be promptly performed. Obtained pericardial fluid should undergo urgent Gram, acid-fast staining.
Bacterial pericarditis-
Purulent fluid,high protein content,leukocyte >10000/ml,massive granulocytes and macrophages
Tuberculous pericarditis-
positive acid fast staining.Serosanguinous fluid, leukocyte >8000/ml,positive adenosine deaminase levels ( >40u/ml ),positive PCR analysis
Blood culture & antibiotic sensitivity testing To detect the causative organism as it can spread through blood.Also to check the drug sensitivity Blood culture & antibiotic sensitivity testing
To detect the causative organism as it can spread through blood.Also to check the drug sensitivity
Chest x ray In pericarditis with mild or no effusion heart appears normal in x ray.Cardiomegaly appears when the effusion exceeds 250 ml
Also a pneumonia may be evident in chest x ray
Chest x ray
In pericarditis with mild or no effusion heart appears normal in x ray.Cardiomegaly appears when the effusion exceeds 250 ml
Also a pneumonia may be evident in chest x ray
Echocardiography Echocardiography is the most useful diagnostic
technique for identifying the presence of pericardial
effusion and quantifying its extent
Echocardiography
Echocardiography is the most useful diagnostic
technique for identifying the presence of pericardial
effusion and quantifying its extent

Investigations - Management

Fact Explanation
Full blood count The white blood cell count will reduce with the treatment Full blood count
The white blood cell count will reduce with the treatment
Echocardiography Echocardiography is the most useful diagnostic
technique for identifying the presence of pericardial
effusion and quantifying its extent
Echocardiography
Echocardiography is the most useful diagnostic
technique for identifying the presence of pericardial
effusion and quantifying its extent
Full blood count High levels of white blood cell counts with increased neutrophil count Full blood count
High levels of white blood cell counts with increased neutrophil count
C reactive protein levels Acute phase proteins will be elevated C reactive protein levels
Acute phase proteins will be elevated
Electrocardiogram ST segment - widespread concave
Frequent PR segment depression
Electrocardiogram
ST segment - widespread concave
Frequent PR segment depression
Chest x ray Cardiomegaly will be evident if there's a pericardial effusion >250ml or if the condition has complicated with heart failure Chest x ray
Cardiomegaly will be evident if there's a pericardial effusion >250ml or if the condition has complicated with heart failure
Troponin I May be elevated as patients may have varying degrees of myocarditis Troponin I
May be elevated as patients may have varying degrees of myocarditis

Management - Supportive

Fact Explanation
Non steroidal anti inflammatory drugs (NSAIDs) For pain relief Non steroidal anti inflammatory drugs (NSAIDs)
For pain relief
Asprin Preferred agent to treat pericarditis after MI (myocardial infarction) as other NSAIDs may interfere with myocardial healing Asprin
Preferred agent to treat pericarditis after MI (myocardial infarction) as other NSAIDs may interfere with myocardial healing
Colchicine If the pericardial pain and inflammation do not respond to NSAIDs or if the acute pericarditis recurs, colchicine has been observed to be effective in relieving pain and preventing recurrent pericarditis Colchicine
If the pericardial pain and inflammation do not respond to NSAIDs or if the acute pericarditis recurs, colchicine has been observed to be effective in relieving pain and preventing recurrent pericarditis

Management - Specific

Fact Explanation
Intravenous antibiotic therapy Effective systemic antibiotic therapy is mandatory (antistaphylococcal antibiotic plus aminoglycoside, followed by tailored antibiotic therapy according to pericardial fluid and blood cultures) Intravenous antibiotic therapy
Effective systemic antibiotic therapy is mandatory (antistaphylococcal antibiotic plus aminoglycoside, followed by tailored antibiotic therapy according to pericardial fluid and blood cultures)
Treatment for tuberculous pericarditis Various combinations of anti tuberculous drugs (Isoniazid,rifampicin,ethambutol and pyrazinamide ) of different lengths (6,9,12 months) have been applied Treatment for tuberculous pericarditis
Various combinations of anti tuberculous drugs (Isoniazid,rifampicin,ethambutol and pyrazinamide ) of different lengths (6,9,12 months) have been applied
Surgical Frequent irrigation of the pericardial cavity with urokinase or streptokinase, using large catheters, may liquefy the purulent exudate, but open surgical drainage through subxiphoid pericardiotomy is preferable. Surgical
Frequent irrigation of the pericardial cavity with urokinase or streptokinase, using large catheters, may liquefy the purulent exudate, but open surgical drainage through subxiphoid pericardiotomy is preferable.
Pericardiectomy Required in patients with dense adhesions, thick purulent effusion, recurrence of tamponade Pericardiectomy
Required in patients with dense adhesions, thick purulent effusion, recurrence of tamponade

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