From the Guidelines
The workup for infectious pericarditis should include a thorough diagnostic evaluation, starting with non-invasive tests such as complete blood count, C-reactive protein, erythrocyte sedimentation rate, and cardiac biomarkers, followed by imaging studies like echocardiography and chest X-ray, and possibly pericardial fluid analysis through pericardiocentesis. The initial evaluation should also include a tuberculin skin test, although it may not be helpful in adults, and consideration of the patient's epidemiological background, as the prevalence of tuberculosis (TB) varies by region 1.
Initial Non-Invasive Evaluation
The diagnostic workup should begin with:
- Auscultation
- ECG
- Transthoracic echocardiography
- Chest X-ray
- Routine blood tests, including markers of inflammation (i.e., CRP and/or ESR), white blood cell count with differential count, renal function, and liver tests, and myocardial lesion tests (CK, troponins) 1.
- Consideration of the patient's clinical presentation, including fever, subacute course, large pericardial effusion, cardiac tamponade, and failure of aspirin or NSAIDs, which are major factors indicating a high risk of specific causes and complications 1.
Pericardiocentesis and Biopsy
Pericardiocentesis is indicated for cardiac tamponade or suspected bacterial and neoplastic pericarditis, with fluid sent for cell count, culture, cytology, and PCR testing for specific pathogens (tuberculosis, viruses) 1. Percutaneous or surgical pericardial biopsy may be considered in selected cases of suspected neoplastic or tuberculous pericarditis.
Imaging and Further Testing
CT and/or CMR are recommended as second-level testing for diagnostic workup in pericarditis, providing additional information about pericardial inflammation and thickness 1. Further testing is indicated in high-risk patients according to the clinical conditions.
Treatment
For suspected bacterial pericarditis, empiric antibiotic therapy should be initiated with coverage for common pathogens while awaiting culture results. For tuberculous pericarditis, standard anti-TB regimens, such as a combination of rifampicin, isoniazid, pyrazinamide, and ethambutol for at least 2 months, followed by isoniazid and rifampicin for a total of 6 months of therapy, are effective 1. Viral pericarditis is typically managed supportively with NSAIDs and colchicine. The workup should be thorough as identifying the specific infectious cause guides appropriate antimicrobial therapy and improves outcomes.
From the Research
Pericarditis Workup for Infection
- The workup for pericarditis involves diagnosing the condition and identifying its cause, which can be infectious, autoimmune, or due to other factors 2, 3, 4, 5.
- The diagnosis of pericarditis is based on the presence of at least two of the following criteria: sharp, pleuritic chest pain, pericardial friction rub, electrocardiographic changes (such as ST-segment elevation and PR depression), and a new or increased pericardial effusion 3, 4.
- Laboratory tests, including blood work and imaging studies (such as chest radiographs, Doppler studies, and transthoracic echocardiography), can help confirm the diagnosis and provide information about the degree of effusion and potential complications 2, 4, 5.
- In cases where an infectious cause is suspected, further testing may be necessary to identify the specific pathogen, such as viral or bacterial cultures, or tests for tuberculosis in endemic areas 3, 5.
Infectious Causes of Pericarditis
- Viral infections are the most common cause of pericarditis in North America and Western Europe, while tuberculosis is a common cause in endemic areas 3, 5.
- Bacterial pericarditis is less common, but can be more severe and requires prompt antibiotic treatment 5.
- The treatment of infectious pericarditis depends on the specific cause and may involve antiviral, antibacterial, or antitubercular therapy, in addition to supportive care with nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine 3, 4, 6, 5.
Treatment and Management
- The treatment of pericarditis typically involves a combination of NSAIDs and colchicine to reduce inflammation and prevent recurrence 3, 4, 6, 5.
- Glucocorticoids may be used in cases where the patient has a contraindication to NSAIDs or colchicine, or in cases of severe or refractory pericarditis 4, 5.
- In cases of recurrent pericarditis, colchicine has been shown to be effective in reducing the risk of recurrence and improving symptoms 6.