What causes pericarditis?

Causes of Pericarditis

Pericarditis is primarily caused by infectious agents (especially viruses in developed countries and tuberculosis globally) and various non-infectious conditions including autoimmune diseases, neoplasms, metabolic disorders, trauma, and medication reactions. 1, 2

Infectious Causes

• Viral infections are the most common cause of pericarditis in developed countries, accounting for 80-90% of cases 2, 3
• Tuberculosis is the leading global cause of pericarditis, particularly in developing countries where it is often associated with HIV infection, especially in sub-Saharan Africa 1, 2
• Bacterial infections (less common) can cause purulent pericarditis through:
  • Direct infection during trauma or procedures
  • Spread from intrathoracic/subdiaphragmatic focus
  • Hematogenous dissemination 4
• Common bacterial pathogens include Staphylococcus, Streptococcus, and Haemophilus species 4
• Purulent pericarditis is a medical emergency with high mortality if untreated 5, 4

Non-Infectious Causes

Autoimmune and Autoinflammatory Conditions

• Systemic autoimmune diseases commonly associated with pericarditis include:
  • Systemic lupus erythematosus
  • Sjögren syndrome
  • Rheumatoid arthritis
  • Scleroderma
  • Systemic vasculitides
  • Sarcoidosis 1, 2
• Autoinflammatory disorders like Familial Mediterranean Fever can cause recurrent pericarditis 2

Neoplastic Causes

• Primary tumors (rare): pericardial mesothelioma
• Secondary metastatic tumors (more common): lung cancer, breast cancer, lymphoma 1, 2

Metabolic Disorders

• Uremia in end-stage renal disease patients (incidence has declined to about 5% in patients starting dialysis) 1, 2
• Myxedema (hypothyroidism)
• Anorexia nervosa 1, 2

Post-Cardiac Injury Syndromes

• Post-myocardial infarction pericarditis (Dressler syndrome)
• Post-pericardiotomy syndrome following cardiac surgery
• Traumatic pericarditis from accidental or iatrogenic thoracic trauma 1, 2
• These syndromes have an immune-mediated pathogenesis with a latent period before symptom onset 1

Medication-Related

• Lupus-like syndrome induced by:
  • Procainamide
  • Hydralazine
  • Methyldopa
  • Isoniazid
  • Phenytoin 1, 6
• Antineoplastic drugs (often with associated cardiomyopathy):
  • Doxorubicin
  • Daunorubicin 1
• Other medications: amiodarone, mesalazine, minoxidil, anti-TNF agents 1

Other Causes

• Hypertension and chronic heart failure 1, 2
• Congenital partial or complete absence of the pericardium (uncommon) 1

Epidemiological Considerations

• Men aged 16-65 years have a higher risk for pericarditis compared to women 1, 2
• Acute pericarditis accounts for approximately 5% of emergency department visits for non-ischemic chest pain in Western countries 5
• Risk factors for poor prognosis include fever >38°C, subacute course, large effusion/tamponade, and failure of NSAID treatment 3

Clinical Implications

• The etiology of pericarditis significantly impacts treatment approach and prognosis 1, 3
• Identifying the underlying cause is crucial for targeted therapy, especially in infectious, neoplastic, and autoimmune cases 2
• Purulent bacterial pericarditis requires urgent drainage and appropriate antibiotics to prevent mortality 4
• Tuberculous pericarditis requires specific anti-tuberculosis therapy and consideration of adjunctive corticosteroids 4