What are the causes of pericarditis?

Causes of Pericarditis

Pericarditis is most commonly caused by viral infections in developed countries, while tuberculosis remains the leading cause worldwide, especially in developing countries. 1

Infectious Causes

• Viral (most common in developed countries) 1, 2

  • Coxsackievirus, echovirus, adenovirus, cytomegalovirus, EBV, HIV

• Bacterial 1, 3

  • Staphylococcus and Streptococcus species (including S. pneumoniae) 4
  • Haemophilus influenzae
  • Mycobacterium tuberculosis (most common worldwide, especially in developing countries)
  • Mycobacterium avium-intracellulare (particularly in HIV/AIDS patients)

• Other infectious agents

  • Fungal
  • Parasitic

Non-Infectious Causes

Autoimmune/Inflammatory (Common) 1, 5, 6

• Systemic lupus erythematosus
• Rheumatoid arthritis
• Sjögren syndrome
• Scleroderma
• Systemic vasculitides
  • Eosinophilic granulomatosis with polyangiitis
  • Horton disease (giant cell arteritis)
  • Takayasu disease
  • Behçet syndrome
• Sarcoidosis
• Familial Mediterranean fever

Neoplastic 1, 5

• Primary tumors (rare)
  • Pericardial mesothelioma
• Secondary metastatic tumors (common)
  • Lung cancer
  • Breast cancer
  • Lymphoma

Metabolic 1, 5

• Uremia
• Myxoedema (hypothyroidism)
• Anorexia nervosa

Traumatic and Iatrogenic 1

• 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 (Dressler's syndrome)
  • Post-pericardiotomy syndrome
  • Post-traumatic
  • Iatrogenic trauma (coronary intervention, pacemaker insertion, radiofrequency ablation)

Drug-Related (Rare) 1

• Lupus-like syndrome (procainamide, hydralazine, methyldopa, isoniazid, phenytoin)
• Antineoplastic drugs (doxorubicin, daunorubicin)
• Other medications: amiodarone, methysergide, mesalazine, clozapine, minoxidil, dantrolene, practolol, phenylbutazone, thiazides, streptomycin, thiouracils, streptokinase, p-aminosalicylic acid, sulfa drugs, cyclosporine, bromocriptine, vaccines, GM-CSF, anti-TNF agents

Other Common Causes 1, 5

• Hypertension
• Chronic heart failure

Other Uncommon Causes 1, 5

• Congenital partial or complete absence of the pericardium
• Chylopericardium (thoracic duct injury)
• Cholesterol pericarditis

Clinical Pearls and Pitfalls

• In up to 80-90% of cases in developed countries, pericarditis is idiopathic or presumed viral 2
• Purulent pericarditis is a serious form of bacterial pericarditis with a 40% mortality rate even with treatment, and is invariably fatal if untreated 3, 4
• Tuberculous pericarditis has a mortality rate approaching 85% if untreated 3
• Certain features at presentation indicate poorer prognosis and need for hospitalization: temperature >38°C, subacute course, large effusion or tamponade, and failure of NSAID treatment 2
• Recurrences may occur in approximately 30% of patients after a first episode of acute pericarditis 1, 2
• The in-hospital mortality rate for acute pericarditis is approximately 1.1%, increasing with age and severe co-infections 1
• Always consider pneumonia-induced purulent pericarditis when a patient presents with pneumonia and pericardial effusion, as this requires emergent intervention 4

When evaluating a patient with suspected pericarditis, a thorough diagnostic workup should focus on identifying the underlying cause, as this will guide specific treatment approaches beyond the standard anti-inflammatory therapy.