What are the causes and treatment options for pericarditis?

Causes of Pericarditis

Pericarditis has multiple etiologies, with viral infections being the most common cause in developed countries, while tuberculous pericarditis predominates worldwide, especially in developing nations and HIV-infected individuals. 1

Infectious Causes

Viral Pericarditis

• Most common etiology in North America and Western Europe, accounting for the majority of idiopathic cases 1, 2
• Causative agents include enteroviruses, herpesviruses (including CMV), parvovirus B19, influenza viruses, and HIV 1
• Often presents after a prodromal viral illness with fever and myalgia 3

Tuberculous Pericarditis

• Leading cause globally, particularly in endemic areas where it accounts for >90% of pericardial disease in HIV-infected individuals and 50-70% in non-HIV-infected individuals 1
• Can present as acute pericarditis, cardiac tamponade, effusive-constrictive disease, or chronic constriction 4
• Mortality approaches 85% if untreated 4

Bacterial (Purulent) Pericarditis

• Occurs via direct infection during trauma, thoracic surgery, catheter drainage, or hematogenous spread 4
• Common organisms include Staphylococcus, Streptococcus, and Haemophilus 4
• Always fatal if untreated, with 40% mortality even with treatment due to tamponade, systemic toxicity, and constriction 4

Fungal Pericarditis

• Primarily affects immunocompromised patients 5
• Caused by endemic fungi (Histoplasma, Coccidioides) or opportunistic fungi (Candida, Aspergillus) 5

Non-Infectious Causes

Post-Cardiac Injury Syndromes

• Develops following cardiac surgery, percutaneous coronary interventions, pacemaker insertion, and catheter ablation 1
• Represents a significant proportion of cases in developed countries 2

Autoimmune/Inflammatory Disorders

• Systemic lupus erythematosus, rheumatoid arthritis, and systemic sclerosis can cause pericarditis 1
• Drug-induced lupus reactions from medications like hydralazine and procainamide 5, 6

Neoplastic Pericarditis

• Results from primary tumors or metastatic disease, particularly lung cancer, breast cancer, lymphoma, and leukemia 1
• Cardiac tamponade is more common with malignant etiology 1

Metabolic Causes

• Renal failure (uremic pericarditis) 6
• Thyroid dysfunction 3

Trauma and Iatrogenic

• Direct injury to the mediastinal area 6
• Complication of cardiac procedures or thoracic surgery 2

Drug and Toxin-Related

• Multiple medications can induce pericarditis through various mechanisms including idiosyncrasy and serum sickness reactions 5

Clinical Pitfalls

A critical caveat: In many cases, no specific cause is identified despite thorough workup, and these are classified as idiopathic pericarditis, which likely represents undiagnosed viral infections 2. The distinction matters because tuberculous and bacterial causes require specific antimicrobial therapy and carry significantly higher mortality and complication rates (20-30% risk of constriction for bacterial causes versus <1% for viral/idiopathic) 1. Therefore, aggressive diagnostic workup is warranted when clinical features suggest these etiologies, particularly in endemic areas, immunocompromised patients, or those with systemic toxicity 4.