What is the full workup and treatment for viral pericarditis?

Workup and Treatment for Viral Pericarditis

The optimal management of viral pericarditis consists of a combination of NSAIDs (aspirin or ibuprofen) plus colchicine as first-line therapy, with treatment duration guided by symptom resolution and C-reactive protein normalization. 1

Diagnostic Workup

Clinical Evaluation

• Look for characteristic symptoms:
  • Sharp, pleuritic chest pain that worsens when supine (present in ~90% of cases) 2
  • Pain that improves with sitting forward
  • Fever
  • Dyspnea

Diagnostic Tests

1. Electrocardiogram (ECG):

   • New widespread ST-segment elevation and PR depression (present in 25-50% of cases) 2
   • Four stages of ECG changes may be observed in pericarditis

2. Laboratory Tests:

   • C-reactive protein (CRP) - elevated in acute phase, used to monitor treatment response 1
   • Complete blood count - may show leukocytosis
   • Cardiac biomarkers (troponin) - to rule out myocardial involvement
   • HIV and HCV serology (only viral serologies recommended) 1

3. Imaging:

   • Echocardiography - to detect pericardial effusion (present in ~60% of cases) 2
   • Chest X-ray - may show enlarged cardiac silhouette if significant effusion present
   • Cardiac MRI - can detect pericardial inflammation through evidence of edema and contrast enhancement 1

4. Advanced Diagnostics (rarely performed in clinical practice):

   • Pericardial fluid analysis and pericardial biopsy with histological, cytological, immunohistological, and molecular investigations may be considered for definitive diagnosis of viral pericarditis 1
   • Note: These are not routinely performed due to complexity, cost, invasiveness, and limited availability 1

Treatment Algorithm

First-Line Therapy

1. NSAIDs with gastroprotection 1, 3

   • Aspirin: 750-1000 mg every 8 hours for 1-2 weeks, then taper by 250-500 mg every 1-2 weeks, OR
   • Ibuprofen: 600 mg every 8 hours for 1-2 weeks, then taper by 200-400 mg every 1-2 weeks

2. Colchicine (added to NSAID therapy) 1, 2

   • 0.5 mg once daily for patients <70 kg
   • 0.5 mg twice daily for patients ≥70 kg
   • Duration: 3 months to reduce recurrence risk
   • Reduces recurrence rate from 37.5% to 16.7% 2

Treatment Monitoring and Duration

• Continue attack doses until complete symptom resolution and CRP normalization 3
• Then begin tapering as outlined above
• Monitor CRP to guide treatment length and assess response 1

Activity Restrictions

• For non-athletes: Restrict exercise until resolution of symptoms and normalization of CRP, ECG, and echocardiogram 1
• For athletes: Restrict exercise for at least 3 months and until resolution of symptoms and normalization of CRP, ECG, and echocardiogram 1

Second-Line Therapy (for refractory cases)

• Low-dose corticosteroids (only if NSAIDs/colchicine fail or are contraindicated, and after infectious causes are excluded) 1
  • Prednisone 0.2-0.5 mg/kg/day (preferred over high doses)
  • Maintain until symptom resolution and CRP normalization, then taper

Important Considerations and Pitfalls

1. Avoid corticosteroids as first-line therapy 1

   • Corticosteroids are explicitly not recommended as first-line treatment
   • They may reactivate viral infections and lead to ongoing inflammation
   • Use only after failure of NSAIDs and colchicine, and when infection has been excluded

2. Recognize recurrent pericarditis

   • Defined as: first episode, symptom-free interval of 4-6 weeks, then recurrence 1
   • Recurrence rate: 15-30% after initial episode, up to 50% after first recurrence without colchicine 1, 2
   • For first recurrence: continue colchicine for at least 6 months 2

3. Viral pericarditis is often associated with myocarditis

   • The condition may be better termed viral myopericarditis 4
   • Monitor for signs of myocardial involvement

4. Antiviral treatments

   • Some experts suggest specific antiviral treatments (IVIG, valganciclovir, interferon-α) based on identified viral etiology 1
   • However, these treatments are still under evaluation and rarely used
   • Infectious disease specialist consultation is recommended if considering antiviral therapy

5. Differentiate from tuberculous pericarditis

   • TB is the most common cause of pericarditis in endemic areas and in immunocompromised patients 5
   • Different treatment approach required for tuberculous pericarditis

By following this evidence-based approach to diagnosis and treatment, most patients with viral pericarditis will have a favorable outcome with resolution of symptoms and low risk of complications.