Causes of Pericarditis
Pericarditis is most commonly caused by viral infections in developed countries, while tuberculosis is the leading cause worldwide, especially in developing countries where TB is endemic. 1
Infectious Causes
Viral Causes
- Most common etiology in developed countries (80-90% of cases) 1, 2
- Common viral agents include:
- Enteroviruses (Coxsackie virus A+B)
- Echoviruses
- Adenoviruses
- Cytomegalovirus (especially in immunocompromised patients)
- Epstein-Barr virus
- Herpes simplex virus
- Influenza viruses
- Parvovirus B19
- Hepatitis C virus
- HIV 1
Bacterial Causes
- Tuberculosis (TB)
- Leading cause worldwide and in developing countries
- Often associated with HIV infection, especially in sub-Saharan Africa 1
- Other bacterial infections:
- Staphylococcus aureus
- Klebsiella pneumoniae
- Mycobacterium avium 1
Fungal Infections
- Less common but can occur, especially in immunocompromised patients 1
Non-Infectious Causes
Autoimmune Conditions (Common)
- Systemic lupus erythematosus
- Sjögren syndrome
- Rheumatoid arthritis
- Scleroderma
- Systemic vasculitides (e.g., eosinophilic granulomatosis with polyangiitis)
- Behçet syndrome
- Sarcoidosis 1
Neoplastic Causes
- Primary tumors (rare) - pericardial mesothelioma
- Secondary metastatic tumors (common)
- Lung cancer
- Breast cancer
- Lymphoma 1
Metabolic Disorders
- Uremia
- Myxedema
- Anorexia nervosa 1
Traumatic and Iatrogenic Causes
- Early onset (rare):
- Direct injury (penetrating thoracic injury, esophageal perforation)
- Indirect injury (non-penetrating thoracic injury, radiation injury)
- Delayed onset (common):
- Post-myocardial infarction syndrome
- Post-pericardiotomy syndrome
- Post-traumatic pericarditis
- Iatrogenic trauma (e.g., coronary percutaneous intervention, pacemaker insertion, radiofrequency ablation) 1
Drug-Related Causes (Rare)
- Lupus-like syndrome: procainamide, hydralazine, methyldopa, isoniazid, phenytoin
- Antineoplastic drugs: doxorubicin, daunorubicin
- Other medications: amiodarone, methysergide, mesalazine, clozapine, minoxidil, dantrolene, phenylbutazone, thiazides, streptomycin, sulfa drugs, cyclosporine, anti-TNF agents 1, 3
Other Causes
- Hypertension and chronic heart failure (common)
- Congenital partial or complete absence of the pericardium (uncommon) 1
Pathophysiology
Inflammatory mechanisms in viral pericarditis involve:
- Direct viral attack on pericardial tissue
- Immune response (antiviral or anticardiac)
- Viral genomic fragments in pericardial tissue serving as antigens to stimulate immune responses
- Deposits of IgM, IgG, and occasionally IgA can persist in the pericardium for years 1
Clinical Implications
- The etiology varies based on epidemiological background, patient population, and clinical setting 1
- Recurrences affect approximately 30% of patients within 18 months after a first episode of acute pericarditis 1
- In-hospital mortality rate for acute pericarditis is approximately 1.1%, increasing with age and severe co-infections 1
- Patients with fever >38°C, subacute course, large effusion or tamponade, and failure to respond to NSAIDs require more extensive evaluation and possible hospitalization 4
Understanding the specific cause of pericarditis is crucial for appropriate treatment and prevention of recurrence, with diagnostic evaluation directed according to clinical presentation and suspicion of specific etiologies.