What is the workup, symptoms, and treatment for viral pericarditis?

Viral Pericarditis: Workup, Symptoms, and Treatment

First-line treatment for viral pericarditis includes aspirin or NSAIDs combined with colchicine, with treatment duration guided by symptom resolution and CRP normalization. 1

Symptoms and Clinical Presentation

Viral pericarditis is diagnosed when at least 2 of the following 4 criteria are present:

• Chest pain (≈90%): Typically sharp, pleuritic, and worsens when lying flat 2
• Pericardial friction rub (<30%): A scratching sound heard on auscultation 2
• ECG changes (≈25-50%): Widespread ST-segment elevation and PR depression 2
• New or worsening pericardial effusion (≈60%): Usually small in size 2

Additional symptoms may include:

• Fever
• Dyspnea
• Preceding viral respiratory or gastrointestinal illness
• Fatigue

Diagnostic Workup

1. Physical examination:

   • Listen for pericardial friction rub
   • Assess for signs of tamponade (jugular venous distension, pulsus paradoxus, hypotension)

2. Laboratory tests:

   • C-reactive protein (CRP): Elevated in acute inflammation and used to guide treatment duration 1
   • Troponin: May be elevated if myocardial involvement (myopericarditis) 1
   • Complete blood count: Leukocytosis suggests inflammation

3. Imaging:

   • ECG: Look for widespread ST elevation, PR depression
   • Chest X-ray: May show enlarged cardiac silhouette if effusion present
   • Echocardiogram: Assess for pericardial effusion, tamponade, and ventricular function 1

4. Advanced testing (in selected cases):

   • Pericardial fluid analysis: For recurrent/refractory cases or when specific etiology is suspected 1
   • PCR or in-situ hybridization of pericardial fluid/tissue: For definitive viral diagnosis 1
   • CMR: Can detect pericardial inflammation through evidence of edema and contrast enhancement 1

Note: Routine viral serology is not recommended, with possible exceptions for HIV and HCV 1

Risk Stratification

Patients should be classified as high, moderate, or low risk:

High-risk features (require hospitalization):

• Fever >38°C
• Subacute onset
• Large pericardial effusion
• Cardiac tamponade
• Failure to respond to NSAIDs
• Immunosuppression
• History of trauma
• Oral anticoagulant therapy

Low-risk patients can be managed as outpatients if they respond to initial NSAID therapy 1

Treatment

First-Line Therapy

1. NSAIDs (with gastroprotection):

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

2. Colchicine (added to NSAID therapy):

   • Weight <70 kg: 0.5 mg once daily for 3 months
   • Weight ≥70 kg: 0.5 mg twice daily for 3 months 1
   • Reduces recurrence risk and improves response to therapy

Second-Line Therapy

Corticosteroids should be considered only when:

• NSAIDs and colchicine have failed or are contraindicated
• Infectious causes have been excluded
• Specific indications exist (e.g., autoimmune disease) 1

Important: Corticosteroids are generally not recommended in viral pericarditis as they may reactivate viral infections and lead to ongoing inflammation 1

Treatment Duration

• Continue initial high-dose anti-inflammatory therapy until symptoms resolve and CRP normalizes 1
• Taper medications gradually to prevent recurrence
• Monitor CRP to guide treatment length 1

Activity Restrictions

• Non-athletes: Restrict exercise until symptoms resolve and CRP, ECG, and echocardiogram normalize 1
• Athletes: Restrict exercise for at least 3 months after symptoms resolve and tests normalize 1

Complications and Prognosis

• Most cases of viral pericarditis have a good long-term prognosis 1
• Recurrence rate: 15-30% without colchicine treatment 1
• Cardiac tamponade is rare in idiopathic/viral pericarditis 1
• Constrictive pericarditis occurs in <1% of viral/idiopathic cases 1

Special Considerations

• Viral pericarditis often presents with associated myocardial involvement (myopericarditis) 3
• Specific antiviral treatments (IVIG, valganciclovir, interferon) are still under evaluation and rarely used 1
• Infectious disease specialist consultation is recommended for severe or refractory cases 1