What is the cause of pericarditis?

Causes of Pericarditis

Pericarditis has diverse infectious and non-infectious etiologies, with viruses being the most common cause in developed countries (North America and Western Europe), while tuberculosis is the predominant cause worldwide, particularly in developing countries where it is often associated with HIV infection. 1, 2

Infectious Causes

Viral Pericarditis

• Viruses are the most frequent etiological agents in developed countries, causing the majority of idiopathic pericarditis cases. 1, 3
• Common viral pathogens include enteroviruses (Coxsackie A and B), echoviruses, adenoviruses, cytomegalovirus, Epstein-Barr virus, herpes simplex virus, influenza virus, parvovirus B19, hepatitis C virus, and HIV. 1, 4, 5
• Enteroviral pericarditis follows seasonal epidemics of Coxsackie virus infections, with highest risk during autumn and winter months. 1, 5
• Cytomegalovirus pericarditis has increased incidence in immunocompromised and HIV-infected patients. 1

Bacterial Pericarditis

• Tuberculosis is the leading cause of pericarditis globally, accounting for >90% of cases in HIV-infected individuals and 50-70% in non-HIV-infected individuals in endemic areas. 1
• In developed countries, tuberculosis accounts for ≤4% of pericardial disease. 1
• Purulent (non-tuberculous) bacterial pericarditis is caused by Staphylococcus, Streptococcus, Haemophilus, and in AIDS patients, Mycobacterium avium-intracellulare. 6
• Bacterial pericarditis occurs through direct infection during trauma or surgery, spread from intrathoracic/myocardial/subdiaphragmatic foci, or hematogenous dissemination. 6

Fungal Pericarditis

• Fungal infections may cause pericardial effusion, particularly in immunocompromised patients. 4

Non-Infectious Causes

Autoimmune and Inflammatory Disorders

• Systemic lupus erythematosus, Sjögren syndrome, rheumatoid arthritis, scleroderma, systemic vasculitides (eosinophilic granulomatosis with polyangiitis, Horton disease, Takayasu disease, Behçet syndrome), and sarcoidosis are associated with pericarditis. 1, 2
• Familial Mediterranean fever and other autoinflammatory conditions cause pericarditis. 2

Neoplastic Causes

• Primary pericardial tumors (rare), predominantly pericardial mesothelioma. 1, 2
• Secondary metastatic tumors (common), especially from lung cancer, breast cancer, and lymphomas. 1, 2, 4

Metabolic and Endocrine Disorders

• Uremia in renal failure patients causes pericarditis. 1, 7
• Myxedema (hypothyroidism) causes pericardial effusion in 5-30% of patients, though tamponade is rare. 4
• Anorexia nervosa is associated with pericarditis. 1, 2

Traumatic and Iatrogenic Causes

• Post-cardiac injury syndromes are common causes, including post-myocardial infarction syndrome (Dressler syndrome), post-pericardiotomy syndrome, and post-traumatic pericarditis following cardiac procedures (percutaneous coronary intervention, pacemaker lead insertion, radiofrequency ablation). 1, 2
• Direct injury from penetrating thoracic trauma or esophageal perforation. 1
• Indirect injury from non-penetrating thoracic trauma or radiation injury (occurs in 6-30% of patients receiving radiation therapy). 4

Drug-Related Causes

• Lupus-like syndrome induced by procainamide, hydralazine, methyldopa, isoniazid, and phenytoin. 2, 4, 7
• Antineoplastic drugs, particularly anthracyclines (doxorubicin, daunorubicin), often associated with cardiomyopathy. 2, 4
• Other medications including amiodarone, methysergide, mesalazine, clozapine, minoxidil, anti-TNF agents, and various chemotherapeutic agents. 4

Cardiovascular Causes

• Hypertension and chronic heart failure are associated with pericarditis. 2
• Pulmonary arterial hypertension causes pericardial effusion in 25-30% of patients, typically small and rarely causing hemodynamic compromise. 4

Epidemiological Considerations

• Men aged 16-65 years have twice the risk (relative risk 2.02) compared to women, with the highest risk difference among young adults. 1, 2
• The incidence of acute pericarditis is 27.7 cases per 100,000 population per year in urban areas, with hospitalization rates of 3.32 per 100,000 person-years. 1
• Pericarditis accounts for 5% of emergency department admissions for chest pain and 0.1-0.2% of all hospital admissions. 1, 3
• In developed countries, up to 50% of cases remain idiopathic despite comprehensive diagnostic evaluation, likely representing undiagnosed viral infections or autoreactive inflammation. 4, 3