Clinical practice. Acute pericarditis

Recurrent Pericarditis and Paradigm Shift in Cardiovascular Imaging and Targeted Therapeutics

Recurrent pericarditis poses a significant challenge to patients and clinicians given its high morbidity and health care burden. Since the last iteration of European Society of Cardiology Guidelines in 2015, further insights have been gained into the pathophysiology, multimodality imaging assessment, and treatment of this condition. The purpose of this review is to discuss each of these aspects and highlight the role of imaging-guided therapy and interleukin-1 inhibitors in autoinflammatory phenotypes that together have transformed the care of these patients. Although future investigations are needed to optimize diagnostic surveillance and timing of therapy, recent evidence points at an encouraging paradigm shift in the treatment of recurrent pericarditis.

Novel Treatments in Refractory Recurrent Pericarditis

Refractory recurrent pericarditis is a troublesome condition that severely impairs the quality of life of affected patients and significantly increases healthcare spending. Until recently, therapeutic options included only a few medications and most of the patients resorted to chronic glucocorticoid treatment with steroid dependence. In the most recent decade, the introduction of interleukin-1 blockers in clinical practice has revolutionized the treatment of glucocorticoid-dependent and colchicine-resistant recurrent pericarditis due to their excellent efficacy and good safety profile. The rationale for the introduction of this class of medications in clinical practice is the autoinflammatory nature of recurrent pericarditis in a substantial rate of cases, with interleukin-1 being the main pro-inflammatory cytokine involved in this context. This review aims to discuss the contemporary available evidence from original research and real-world data on interleukin-1 blocker use in refractory recurrent pericarditis, in terms of indications, mechanism of action, efficacy, side effects, and recommended treatment protocols. Moreover, novel treatment proposals, such as hydroxychloroquine, beta blockers, and cannabidiol, which showed encouraging preliminary results, are addressed. Finally, gaps in knowledge, unmet needs, and future perspectives related to recurrent pericarditis are thoroughly discussed.

Asymptomatic Chronic Large Pericardial Effusions: To Drain or to Observe?

Pericardial effusions, especially large ones, have traditionally been regarded with concern by clinicians due to the sometimes unpredictable development of life-threatening cardiac tamponade. In the European Society of Cardiology Guidelines on pericardial diseases, the simplified algorithm for pericardial effusion triage and management recommends pericardial drainage in cases of cardiac tamponade and/or suspicion of bacterial or neoplastic etiology. In the presence of acute pericarditis, empiric anti-inflammatory treatment should be given, while when a specific indication known to be associated with pericardial effusion is found, then treatment of the underlying cause is indicated. Notably, the most challenging subgroup of patients includes those with large, asymptomatic, C-reactive-protein-negative, idiopathic effusions. In the latter subjects, pericardial drainage is proposed in cases of chronic effusions (lasting more than three months). However, this recommendation is based on scant data stemming from small-sized non-randomized studies. Nevertheless, recent evidence in a larger cohort of patients pointed out that a watchful waiting strategy is a safe option in terms of complication-free survival. This review summarizes the contemporary evidence on this challenging topic and provides recommendations for tailoring individual patient treatments.

Management of postpartum preeclampsia complicated by idiopathic pericarditis: A case report

This case report discusses the rare occurrence of pericarditis with preeclampsia in the antepartum through to postpartum state. A woman in her 30s presented four days postnatally with positional central chest pain, elevated blood pressure and newly deranged liver function tests. Echocardiogram demonstrated new pleural effusion and she was diagnosed with preeclampsia and superimposed pericarditis. Her blood pressure was stabilised with a combination treatment regime of labetalol, enalapril and frusemide, whilst her pericarditis responded well to colchicine and ibuprofen. She was eventually discharge on enalapril and colchicine. By her 6-week follow-up she had made a full recovery and she had reported no recurrence of symptoms at the time of writing.

Purulent Pericarditis in End-Stage Renal Disease: A Rare Case of Citrobacter freundii Infection

BACKGROUND

Purulent pericarditis is a rare but life-threatening condition, particularly challenging when it occurs in immunocompromised individuals.

CASE REPORT

We present the case of a 68-year-old man with end-stage renal disease who developed purulent pericarditis secondary to Citrobacter freundii infection. Despite initial challenges in diagnosis and management, the patient showed a favorable response to antibiotic therapy.

CONCLUSIONS

This case highlights the importance of prompt recognition and treatment of purulent pericarditis, especially in patients with underlying immunosuppression and comorbidities.

Re-enforcing High-Risk Acute Pericarditis Requiring Hospital Admission: An Unusual Case of Critical Idiopathic Acute Pericarditis Presenting As Tamponade and Pleuro-Pericardial Complications in a Patient Presenting With Flu-Like Symptoms

Pericarditis is an inflammatory process that affects the pericardium, the fibrous sac surrounding the heart. Acute pericarditis accounts for approximately 0.1% of inpatient admissions and 5% of non-ischemic chest pain visits to the emergency departments (EDs). Most patients who present with acute pericarditis have a benign course and good prognosis. However, a rare percent of the patients develop complicated pericarditis. Examples of complications include pericardiac effusion, cardiac tamponade, constrictive pericarditis, effusive and constrictive pericarditis and, even more rarely, large pleural effusion The occurrence of complicated pericarditis can lead to high morbidity and mortality if not urgently managed in most patients. Our case presents a 60-year-old male that presented to the emergency room with flu-like symptoms. However, the viral panel test was negative. He initially got discharged with supportive care but was brought back to the ED by his wife in a critical, life-threatening state due to pericarditis symptoms complicated by tamponade and shock. His condition required urgent intervention and critical level of care. The patient's course was also complicated by myopericarditis and recurrent bilateral pleural effusions, which required therapeutic interventions. This unique case presents the patient group that develop multiple life-threatening complications of acute pericarditis, including cardiac tamponade and shock, affecting several end organs. This case also highlights clues to the predisposing factors to complications of acute pericarditis. Patients who present with high-risk signs and symptoms indicating poorer prognosis warrant further observation and admission. This will also add to the literature reviews regarding the risk factors associated with development of complicated acute pericarditis. This will also serve as a review of pathophysiology, etiology, current diagnosis and available novel treatment for such patients.

Purulent pericarditis caused by methicillin-sensitive Staphylococcus aureus bacteriuria

BACKGROUND

Purulent pericarditis (PP)- a purulent infection involving the pericardial space-requires a high index of suspicion for diagnosis as it often lacks characteristic signs of pericarditis and carries a mortality rate as high as 40% even with treatment. Common risk factors include immunosuppression, diabetes mellitus, thoracic surgery, malignancy, and uremia. Most reported cases of PP occur in individuals with predisposing risk factors, such as immunosuppression, and result from more commonly observed preceding infections, such as pneumonia, osteomyelitis, and meningitis. We report a case of PP due to asymptomatic bacteriuria in a previously immunocompetent individual on a short course of high-dose steroids.

CASE PRESENTATION

An 81-year-old male presented for severe epigastric pain that worsened with inspiration. He had been on high-dose prednisone for presumed inflammatory hip pain. History was notable for urinary retention requiring intermittent self-catheterization and asymptomatic bacteriuria and urinary tract infections due to methicillin-sensitive Staphylococcus aureus (MSSA). During the index admission he was found to have a moderate pericardial effusion. Pericardial fluid cultures grew MSSA that had an identical antibiogram to that of the urine cultures. A diagnosis of purulent pericarditis was made.

CONCLUSION

PP requires a high index of suspicion, especially in hosts with atypical risk factors. This is the second case of PP occurring as a result of asymptomatic MSSA bacteriuria. Through reporting this case we hope to highlight the importance of early recognition of PP and the clinical implications of asymptomatic MSSA bacteriuria in the setting of urinary instrumentation and steroid use.

Chronic Pericardial Effusion: Causes and Management

Chronic pericardial effusion is a common pericardial syndrome whose approach has been well standardised in recent years. The main challenge associated with this condition is the progression (sometimes unheralded) to cardiac tamponade. Pericardial effusions may present either as an isolated finding or in the context of a specific etiology including autoimmune, neoplastic, or metabolic disease. Among investigations used during diagnostic work-up, echocardiography is of paramount importance for the diagnosis, sizing, and serial evaluation of the hemodynamic impact of effusions on heart diastolic function. In an individualised manner, advanced imaging including computed tomography and cardiac magnetic resonance imaging should be performed, especially if baseline tests are inconclusive. Triage of these patients according to the most recent 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial diseases should take into account the presence of hemodynamic compromise as well as suspicion of malignant or purulent pericarditis as first step, C-reactive protein serum level measurement as second step, investigations for a specific condition known to be associated with pericardial effusion as third step, and finally the size and the duration of the effusion. Treatment depends on the evaluation of the above-mentioned parameters and should ideally be tailored to the individual patient. Prognosis of chronic pericardial effusions depends largely on the underlying etiology. According to novel data, the prognosis of individuals with idiopathic, chronic (> 3 months), large (> 2 cm), asymptomatic pericardial effusions is usually benign and a watchful waiting strategy seems more reasonable and cost-effective than routine drainage as previously recommended.

Cardiovascular involvement in Epstein-Barr virus infection

Cardiovascular involvement is an uncommon but severe complication of Epstein-Barr virus (EBV) infection caused by direct damage and immune injury. Recently, it has drawn increasing attention due to its dismal prognosis. It can manifest in various ways, including coronary artery dilation (CAD), coronary artery aneurysm (CAA), myocarditis, arrhythmias, and heart failure, among others. If not treated promptly, cardiovascular damage can progress over time and even lead to death, which poses a challenge to clinicians. Early diagnosis and treatment can improve the prognosis and reduce mortality. However, there is a lack of reliable large-scale data and evidence-based guidance for the management of cardiovascular damage. Consequently, in this review, we attempt to synthesize the present knowledge of cardiovascular damage associated with EBV and to provide an overview of the pathogenesis, classification, treatment, and prognosis, which may enhance the recognition of cardiovascular complications related to EBV and may be valuable to their clinical management.

Myocarditis as a Complication of Campylobacter jejuni-Associated Enterocolitis: A Report of Two Cases

Myocarditis refers to inflammation of the heart muscle and may occur individually or together with pericarditis, which refers to inflammation of the saclike tissue layer that surrounds the heart. They may have infectious or non-infectious etiologies. Campylobacter jejuni, a major cause of gastroenteritis worldwide, may also cause myocarditis in rare situations. We present two cases highlighting this rare complication of diarrheal disease caused by Campylobacter jejuni infection and subsequent development of myocarditis. Both patients presented with chest pain and multiple episodes of watery diarrhea, with initial EKGs showing ST segment changes, as well as elevated inflammatory markers and elevated troponins. GI panels for both patients were positive for Campylobacter jejuni. Based on their presentations and investigative findings, they were diagnosed with myocarditis secondary to Campylobacter infection, and their symptoms subsided with appropriate management. It is unclear if the myocardial damage, in this case, is a direct effect of the toxin on cardiac myocytes or secondary to an immunologic phenomenon. Regardless, Campylobacter jejuni-associated myocarditis remains a rare phenomenon and needs to be considered in the differential of patients presenting with concurrent chest pain and diarrheal symptoms.

Pediatric Pericarditis: Update

PURPOSE OF REVIEW

While there have now been a variety of large reviews on adult pericarditis, this detailed review specifically focuses on the epidemiology, clinical presentation, diagnosis, and management of pediatric pericarditis. We have tried to highlight most pediatric studies conducted on this topic, with special inclusion of important adult studies that have shaped our understanding of and management for acute and recurrent pericarditis.

RECENT FINDINGS

We find that the etiology of pediatric pericarditis differs from adult patients with pericarditis and has evolved over the years. Also, with the current COVID-19 pandemic, it is important for pediatric clinicians to be aware of pericardial involvement both due to the infection and from vaccination. Oftentimes, pericarditis maybe the only cardiac involvement in children with COVID-19, and so caregivers should maintain a high index of suspicion when they encounter children with pericarditis.  Large-scale contemporary epidemiological data regarding incidence and prevalence of both acute and recurrent pericarditis is lacking in pediatrics, and future studies should focus on highlighting this important research gap. Most of the current management strategies for pediatric pericarditis are from experiences gathered from adult data. Pediatric multicenter trials are warranted to understand the best management strategy for those with acute and recurrent pericarditis.

CASE VIGNETTE

A 6-year-old child with a past history of pericarditis almost 2 months ago comes in with a 2-day history of chest pain and fever. Per mother, he stopped his steroids about 2 weeks ago, and for the last 2 days has had a temperature of 102F and has been complaining of sharp mid-sternal chest pain that gets worse when he lies down and is relieved when he sits up and leans forward. On examination, he is tachycardic (heart rate 160 bpm), with normal blood pressure for age. He appears to be in pain (5/10), and on auscultation has a pericardial friction rub. His lab studies are notable for elevated white blood cell count and inflammatory markers (CRP and ESR). His electrocardiogram reveals sinus tachycardia and diffuse ST-elevation in all precordial leads. His echocardiogram demonstrates normal biventricular function and a trace pericardial effusion. His cardiac MRI confirms recurrent pericarditis. He is started on indomethacin and colchicine. He has complete resolution of his symptoms by day 3 of admission and is discharged with close follow-up.

A Rare Case of Primary Purulent Pericarditis Caused by Streptococcus constellatus

Background: Bacteria-caused acute pericarditis is a very rare entity. It is usually associated with an underlying infection or compromised immune system. Primary purulent pericarditis in a previously healthy individual is highly unexpected; therefore, it is likely to have a delayed diagnosis and poor outcomes. Case: We report a case of an adult immunocompetent patient with primary bacterial pericarditis caused by a member of the commensal oral flora Streptococcus constellatus. The patient presented with septic shock and cardiac tamponade, and was further complicated with constrictive pericarditis, which was successfully treated with pericardiectomy. Conclusions: Bacterial pericarditis is a fulminant disease with a high mortality and complication rate. Fast recognition and prompt therapy are required to achieve a full recovery.

A case of Takayasu arteritis complicated with acute pericarditis at initial presentation

Takayasu arteritis (TAK) is a rare, large-vessel vasculitis, frequently presenting at approximately 20 years of age. Patients with TAK without characteristic clinical findings are sometimes left undiagnosed and are followed by a fever of unknown origin; delayed diagnosis may lead to irreversible ischaemia and organ damage. Here, we report a case of an 18-year-old woman with TAK complicated by acute pericarditis at initial presentation. She was diagnosed with idiopathic acute pericarditis and treated with non-steroidal anti-inflammatory drugs (NSAIDs). However, the patient's fever and pain in the chest and upper back persisted. On admission to our hospital, magnetic resonance angiography and ultrasonography revealed wall thickening in the common carotid artery, subclavian artery, and aorta, along with vascular narrowing in the celiac, superior mesenteric, and bilateral renal arteries. The patient was diagnosed with TAK and treated with glucocorticoids, including methylprednisolone pulse therapy, and azathioprine. The treatment improved the patient's signs and symptoms, and pericardial effusion decreased. Acute pericarditis is a rare manifestation of TAK, but it is important to differentiate diseases, including TAK in patients with acute pericarditis who fail to respond to 2-3 weeks of conventional therapy with NSAIDs.

Cardiovascular complications of COVID-19 vaccines: A review of case-report and case-series studies

BACKGROUND

There are multiple reviews on cardiovascular aspects of COVID-19 disease on cardiovascular system in different population but there is lack of evidence about cardiovascular adverse effects of COVID vaccines.

OBJECTIVES

The purpose of this study was to compare the cardiac complications of COVID19 vaccines, based on vaccine type (mRNA, vector-based, and inactivated vaccines).

METHODS

A systematic search was performed covering PubMed for English case-reports and case-series studies, and finally 100 studies were included.

RESULTS

Myocarditis (with overall rate around 1.62%) was shown to be the most common post-COVID19 immunization cardiac event. More than 90% of post-COVID19 vaccination myocarditis occurred after receiving mRNA vaccines (Moderna & Pfizer-BioNTech), but the report of this event was less in the case of vector-based vaccinations and/or inactivated vaccines. Myocarditis was reported more commonly in men and following the second dose of the immunization. Takotsubo cardiomyopathy (TTC) was reported after mRNA (more commonly) and vector-based vaccinations, with no case report after inactivated vaccines. When mRNA and vector-based vaccinations were used instead of inactivated vaccines, a greater frequency of vaccine-induced thrombotic thrombocytopenia (VITT) and pulmonary emboli (PE) was reported. Myocardial infarction/cardiac arrest was recorded in those beyond the age of 75 years.

CONCLUSION

The personal and public health benefits of COVID-19 vaccination much outweigh the minor cardiac risks. Reporting bias, regarding more available mRNA vaccines in developed countries, may conflict these results.

Breast Cancer Complicated by Cardiac Tamponade in a Patient With Neurofibromatosis Type 1

Pericardial effusion may occur as a result of malignant pericarditis, which may in turn result in cardiac tamponade. This paper reports on a rare case of cardiac tamponade that occurred in an African American patient with breast cancer and neurofibromatosis. Herein, we present a case of a 38-year-old woman with neurofibromatosis type 1 (NF1) and breast cancer. She presented with sudden shortness of breath and hypotension. Computed tomography of the chest and an echocardiogram confirmed the presence of cardiac tamponade. Symptomatic relief was obtained following an emergency pericardiocentesis. The patient experienced a recurrence of symptomatic pleuro-pericardial effusion, requiring repeat therapeutic pericardiocentesis and thoracocentesis. To eliminate accumulating fluid, an indwelling drain was placed. The clinical condition of the patient, however, continued to deteriorate and she expired a few days after admission. When patients with breast cancer present with dyspnea, clinicians should maintain a high index of suspicion of cardiac tamponade; urgent imaging should be performed to exclude tamponade. Further research is needed to identify the factors that predict cardiac tamponade in breast cancer patients as well as the optimal treatment for the condition. It is also necessary to examine the relationship between a history of neurofibromatosis and cardiac tamponade.

Bacterial Pericarditis Caused by Campylobacter fetus subsp. fetus After Mutton Consumption

Campylobacter fetus subsp. fetus causes systemic diseases including bacteremia and meningitis. However, it rarely causes bacterial pericarditis. We present a rare case of bacterial pericarditis caused by Campylobacter fetus subsp. fetus. A man in his 60s presented with a fever and dyspnea. Electrocardiography revealed ST segment elevation in all leads except augmented vector right (aVR), and contrast-enhanced computed tomography of the chest revealed a large pericardial effusion. Campylobacter fetus subsp. fetus, appearing as curved, gull-wing-shaped gram-negative rods on microscopy, was identified on blood culture. The patient was diagnosed with acute pericarditis caused by Campylobacter fetus subsp. fetus. Further, history-taking revealed that he had consumed undercooked mutton before the onset of his illness. He recovered after treatment with antibiotics (ceftriaxone, ampicillin, and amoxicillin) for four weeks. With a blood culture revealing gull-wing shaped gram-negative rods, and the patient's history including potential contact with animals or the consumption of raw or undercooked meat, Campylobacter fetus subsp. fetus infection should be suspected.

Proton beam therapy causing pericarditis – a rare case of radiation induced cardiotoxicity

Acute pericarditis is caused by the inflammation of the pericardium which can result in an effusion around the heart. Proton beam therapy causing radiation-induced pericarditis is not a well-known cause of pericarditis. We present a case of a patient with Li-Fraumeni Syndrome who developed acute onset pericarditis, presumed to be secondary to proton beam therapy.

A case report of primary meningococcal pericarditis secondary to Neisseria meningitidis in a young female patient

Pericarditis is responsible for approximately 5 % of emergency admissions due to chest pain. Pericarditis secondary to Neisseria meningitidis (meningococci) was originally reported in 1918, and remains a rare diagnosis. We report a case of primary meningococcal pericarditis presenting with non-specific symptoms, illustrating the importance of considering rarer causes of pericardial effusion. A previously fit and well 23-year-old female presented to her local hospital with a 2-day history of feeling generally unwell with myalgia and fevers and was initially discharged. Four days following discharge the patient re-presented with worsening symptoms. A Computed Tomography Pulmonary Angiogram (CTPA) demonstrated a large pericardial effusion with subsequent bedside echocardiogram confirming a global pericardial effusion of up to 3 cm. This required drainage, with blood cultures and pericardial fluid showing polymerase chain reaction positivity for Neisseria meningitidis, serogroup B. Our report describes a rare case of Primary Meningococcal Pericarditis secondary to serotype B meningococcal infection. The European Society of Cardiology propose criteria that warrant hospital admission and an aetiology search for certain patients with pericardial disease. These criteria provide a useful framework to help select those minority of patients in whom a more serious underlying cause is present. Blood cultures provide vital information to allow us to complete a thorough aetiological search and empirical antibiotics can cloud the clinical picture, making it harder to identify causative organisms. To aid the early administration of appropriate therapy, it may be pertinent to recommend a low threshold for taking blood cultures in patients with pyrexia and pericarditis or pericardial effusion.

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Pericarditis caused by Meningococcus is rare but serious.

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Consider alternative causes of pericarditis, particularly in young people.

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Patients with bacterial pericardial effusions have high mortality and morbidity.

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Early blood cultures are essential for treating rarer forms of pericarditis.

Influenza Type B Complicates a Previously Undiagnosed Case of Pericarditis

We report the first case of pericarditis exacerbation due to influenza B viral infection while emphasizing the importance of cardiac magnetic resonance (CMR) for the timely diagnosis and ruling out of non-effusive pericarditis in a patient with compatible, unexplained chest pain. The patient presented with left-sided chest pain that was partially relieved by leaning backward and noted persistent fatigue for several days. Pericardial friction rub, electrocardiogram (ECG), and echocardiogram abnormalities were not detected. After discharge on the morning following admission, fatigue and fever several minutes after physical exertion continued. The patient contracted influenza type B, leading to pneumonia and a second hospitalization, during which echocardiography showed moderate pericardial effusion. We conclude that the patient had pericarditis on the first admission because other compatible causes of chest pain were ruled out, symptoms were compatible with non-effusive pericarditis and could not be ruled out since CMR was not done, and the patient tested positive during his second admission for multiple known etiologic agents of pericarditis. We highlight the importance of CMR in screening patients presenting with chest pain of unknown origin to facilitate early detection and intervention.

Cardiotoxicity induced by immune checkpoint inhibitor: The complete insight into mechanisms, monitoring, diagnosis, and treatment

Immune checkpoint inhibitors (ICIs) have been taking cancer research by storm as they provide valuable therapeutic benefits to cancer patients in terms of immunotherapy. Melanoma and non-small cell lung cancer (NSCLC) are among the most prevalent cancer varieties that were utilized in ICI trials with many other cancer types being involved too. Despite impressive clinical benefits of overall response rate (ORR), progression-free survival (PFS), etc., ICIs are also accompanied by various immune-related adverse events (irAEs). Amongst the irAEs, cardiotoxicity bags a crucial role. It is of paramount importance that ICI-induced cardiotoxicity should be studied in detail due to its high mortality rate although the prevalence rate is low. Patients with ICI cardiotoxicity can have a greatly enhanced life quality despite adverse reactions from ICI therapy if diagnosed early and treated in time. As such, this review serves to provide a complete insight into the predisposing factors, mechanism, diagnostic methods and treatment plans revolving around ICI-induced cardiotoxicity.

A Systematic Review of COVID-19 and Pericarditis

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China in December 2019. Since then, the disease has spread globally, leading to the ongoing pandemic. It can cause severe respiratory illness; however, many cases of pericarditis have also been reported. This systematic review aims to recognize the clinical features of pericarditis and myopericarditis in COVID-19 patients.

Google Scholar, Medline/PubMed, CINAHL, Cochrane Central, and Web of Science databases were searched for studies reporting “Coronavirus” or “COVID” and “Peri-myocarditis,” “heart,” or “retrospective.” Case reports and retrospective studies published from May 2020 to February 2021 were reviewed.

In total, 33 studies on pericarditis, myopericarditis, and pericardial infusion were included in this review. COVID-19 pericarditis affected adult patients at any age. The incidence is more common in males, with a male-to-female ratio of 2:1. Chest pain (60%), fever (51%), and shortness of breath (51%) were the most reported symptoms, followed by cough (39%), fatigue (15%), myalgia (12%), and diarrhea (12%). Laboratory tests revealed leukocytosis with neutrophil predominance, elevated D-dimer, erythrocyte rate, and C-reactive protein. Cardiac markers including troponin-1, troponin-T, and brain natriuretic peptide were elevated in most cases. Radiographic imaging of the chest were mostly normal, and only 31% of chest X-rays showed cardiomegaly and or bilateral infiltration. Electrocardiography (ECG) demonstrated normal sinus rhythm with around 59% ST elevation and rarely PR depression or T wave inversion, while the predominant echocardiographic feature was pericardial effusion. Management with colchicine was favored in most cases, followed by non-steroidal anti-inflammatory drugs (NSAIDs), and interventional therapy was only needed when patient developed cardiac tamponade. The majority of the reviewed studies reported either recovery or no continued clinical deterioration.

The prevalence of COVID-19-related cardiac diseases is high, and pericarditis is a known extrapulmonary manifestation. However, pericardial effusion and cardiac tamponade are less prevalent and may require urgent intervention to prevent mortality. Pericarditis should be considered in patients with chest pain, ST elevation on ECG, a normal coronary angiogram, and COVID-19. We emphasize the importance of clinical examination, ECG, and echocardiogram for decision-making, and NSAIDs, colchicine, and corticosteroids are considered to be safe in the treatment of pericarditis/myopericarditis associated with COVID-19.

Descriptive Study of Pericarditis Outcomes in Different Etiologies and Risk Factors: A Retrospective Record Review

Background: Pericarditis is an inflammatory pericardial disorder that can be caused by several infectious and non-infectious illnesses. Coronavirus disease 2019 (COVID-19) was recently added to the long list of pericarditis causes. As a result, this study aims to look at the incidence of various etiologies of pericarditis, including post-COVID-19 vaccine and risk factors, at King Abdulaziz University Hospital in Jeddah, Saudi Arabia.

Methods: Between 2012 and 2022, all male and female patients diagnosed with acute, chronic, or constrictive pericarditis at the King Abdulaziz University Hospital clinic were included in this retrospective study, which took place in June 2022. Data were collected from the hospital's medical records, including the patient's demographic information, pericarditis history, medical history, social background, laboratory tests, Echocardiogram (ECHO) and electrocardiogram (ECG) readings, and medication history. Associations were tested using univariate and bivariate analysis.

Results: Acute pericarditis was diagnosed in 59 (89.1%) patients and the most common symptoms were chest pain and shortness of breath (SOB) followed by fever and cough.Idiopathic pericarditis was the primary etiology 30 (46.9%) with male predominance 25 (55.6%), followed by infections and then cardiac presenting primarily with chest pain 25 (83.3%). In comparison, the most common presentation in females was autoimmune, as seen in eight patients (42.1%). Most patients required aspirin, ibuprofen, and colchicine. Among outcomes, of a total of 64 patients, five died within 30 days. Moreover, four (7.5%) experienced subsequent cardiac tamponades, which was mainly due to malignancy (50%) (p<0.05).

Conclusion: There was a substantial relationship between malignancy and developing morbid complications, with 59 patients out of 64 getting acute pericarditis and the remainder chronic and constrictive pericarditis with idiopathic pericarditis being the leading causes.

Malignant Cardiac Tamponade: A Complication of Untreated Breast Cancer

Carcinomatous pericarditis is a rare complication of locally aggressive breast cancer in which malignant cells directly extend into the pericardium causing inflammation and creating a pericardial effusion. A 40-year-old woman with untreated metastatic breast cancer presented to an outpatient clinic in significant distress with symptoms of progressive shortness of breath and bilateral leg swelling. An urgent echocardiogram demonstrated a large pericardial effusion with echocardiographic evidence of cardiac tamponade. She underwent emergent pericardiocentesis of the effusion that was deemed to be malignant after cytologic evaluation. Subsequently, she opted for palliative treatment involving the surgical creation of a right pericardial window and placement of an indwelling pleural catheter. Internists should maintain a high index of suspicion for malignant cardiac tamponade in at-risk patients, especially those with locally aggressive and advanced malignancies.

Cardiac tamponade and constrictive pericarditis due to Actinomyces meyeri bacterial pericarditis: a case report

Background

Purulent bacterial pericarditis (PBP) is a highly lethal infection of the pericardial space that arises as a complication of infective illnesses. Purulent bacterial pericarditis remains a diagnostic challenge given its non-specific clinical and investigative features and carries exceedingly high mortality rates due to fulminant sepsis and morbidity including constrictive pericarditis in survivors. We present our management of cardiac tamponade and subsequent constrictive pericarditis due to Actinomyces meyeri PBP.

Case summary

A 53-year-old Caucasian male presented with acute New York Heart Association Class IV dyspnoea and chest discomfort, in the context of multiple hospital presentations over the preceding 8 weeks due to presumed recurrent viral pericarditis. On this admission, initial transthoracic echocardiography (TTE) demonstrated a large asymmetric pericardial effusion for which he underwent urgent pericardiocentesis. Serial TTE post-pericardiocentesis, however, demonstrated effusion re-accumulation and effusive-constrictive pericarditis, confirmed on cardiac magnetic resonance imaging. Fluid culture was positive for A. meyeri. He was diagnosed with PBP, but his condition deteriorated despite appropriate intravenous antibiotic therapy, necessitating semi-urgent surgical pericardiectomy. He recovered well and was discharged on Day 10 post-operatively.

Discussion

Unlike uncomplicated acute viral or idiopathic pericarditis, PBP portends a very poor prognosis if unrecognized and untreated. Diagnostic challenges persist given its rarity in modern clinical practice; however, PBP should be considered in cases of seemingly recurrent pericarditis. Multi-modal cardiac imaging and careful analysis of pericardial fluid including cultures and lactate dehydrogenase/serum ratios may assist in earlier recognition. In this case, source control and symptom relief were achieved only with combined intravenous antibiotics, surgical evacuation, and pericardiectomy.

Streptococcus anginosus purulent pericarditis with cardiac tamponade presenting as a complication of postobstructive pneumonia

A man in his 60s with stage 3 squamous cell carcinoma of the left lung status postchemotherapy and radiation therapy presented with mixed septic and obstructive shock with multiorgan dysfunction. Initial electrocardiogram showed sinus tachycardia and diffuse concaved ST elevation. Transthoracic echocardiogram revealed pericardial effusion with tamponade physiology. CT thorax was notable for dense left lung consolidation with pleural effusion. Emergent pericardiocentesis and percutaneous balloon pericardiotomy were performed which successfully drained 500 mL of purulent pericardial fluid. A left chest tube was placed and revealed a large volume of empyema. Both pericardial and pleural fluid cultures yielded similar strains of Streptococcus anginosus The patient was initially treated with empiric broad-spectrum intravenous antibiotics which were eventually de-escalated to intravenous ceftriaxone based on microbiology culture and sensitivity. Unfortunately, the patient developed pulseless electrical activity arrest on day 10 of intensive care unit stay and expired despite cardiopulmonary resuscitation.

Incidence, clinical presentation, management, and outcome of acute pericarditis and myopericarditis

AIMS

Little is known about the epidemiology, clinical presentation, management, and outcome of acute pericarditis and myopericarditis.

METHODS AND RESULTS

The final diagnoses of acute pericarditis, myopericarditis, and non-ST-segment elevation myocardial infarction (NSTEMI) of patients presenting to seven emergency departments in Switzerland with acute chest pain were centrally adjudicated by two independent cardiologists using all information including serial measurements of high-sensitivity cardiac troponin T. The overall incidence of pericarditis and myopericarditis was estimated relative to the established incidence of NSTEMI. Current management and long-term outcome of both conditions were also assessed. Among 2533 chest pain patients, the incidence of pericarditis, myopericarditis, and NSTEMI were 1.9% (n = 48), 1.1% (n = 29), and 21.6% (n = 548), respectively. Accordingly, the estimated incidence of pericarditis and myopericarditis in Switzerland was 10.1 [95% confidence interval (95% CI) 9.3-10.9] and 6.1 (95% CI 5.6-6.7) cases per 100 000 population per year, respectively, vs. 115.0 (95% CI 112.3-117.6) cases per 100 000 population per year for NSTEMI. Pericarditis (85% male, median age 46 years) and myopericarditis (62% male, median age 56 years) had male predominance, and commonly (50% and 97%, respectively) resulted in hospitalization. No patient with pericarditis or myopericarditis died or had life-threatening arrhythmias within 30 days [incidence 0% (95% CI 0.0-4.8%)]. Compared with NSTEMI, the 2-year all-cause mortality adjusted hazard ratio of pericarditis and myopericarditis was 0.40 (95% CI 0.05-2.96), being 0.59 (95% CI 0.40-0.88) for non-cardiac causes of chest pain.

CONCLUSION

Pericarditis and myopericarditis are substantially less common than NSTEMI and have an excellent short- and long-term outcome.

CLINICAL TRIAL REGISTRATION

ClinicalTrial.gov, number NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.

Cardiac Tamponade After COVID-19 Vaccination

BACKGROUND

Acute pericarditis is a diffuse inflammation of the pericardial sac with many well-defined etiologies. Acute pericarditis as a vaccine-related adverse event is a rare entity, and the association between pericarditis and the immunogenic response to Coronavirus disease 2019 (COVID-19) vaccines is still being fully characterized.

CASE REPORT

A previously healthy 18-year-old man presented with fever, pleuritic chest pain, and shortness of breath 3 weeks after receiving the first dose of a COVID-19 mRNA-based vaccine. The patient was found to have a large pericardial effusion with early tamponade physiology requiring pericardiocentesis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As COVID-19 vaccination becomes more prevalent globally, physicians should be aware of pericarditis as a rare but potentially serious adverse reaction. Although a direct causal link cannot be demonstrated, we present this case to increase awareness among emergency physicians of pericarditis as a rare, but potentially serious adverse event associated with COVID-19 vaccination.

A Rare Case of Addison's Disease Presenting With Intermittent Pancytopenia and Cardiac Tamponade

Objective

To report the first case, to our knowledge, of intermittent pancytopenia and cardiac tamponade occurring together in association with Autoimmune Addison's Disease (AAD).

Methods

A 21 year-old woman presented on three different occasions with multiple complaints. Her evaluation was significant for intermittent pancytopenia (white blood cell, 1.3-3.0 × 10³/μL [normal 4.5-11 × 10³]; hemoglobin, 8.8-9.6 g/dL [11-16]; and platelets, 102-117 × 10³/μL [150-400 × 10³/μL]) and pericardial effusion with cardiac tamponade. Further investigation including a morning serum cortisol level of 0.6 μg/dL (5.27-22.45 μg/dL), adrenocorticotropic hormone level of 1027 pg/mL (normal 6-50 pg/mL), and positive 21-hydroxylase antibodies confirmed the diagnosis of primary adrenal insufficiency due to AAD. Treatment with steroids resulted in prompt hemodynamic recovery with normalization of all blood cell lines.

Results

The diagnosis of AAD is often delayed or overlooked. Pancytopenia occurring in AAD is most likely due to either marrow suppression in the setting of acute illness and exacerbated by hypoadrenalism or possibly an autoimmune-mediated marrow reaction. Pericarditis with cardiac tamponade has been described in AAD occurring in the setting of polyglandular autoimmune syndrome type II. The pathogenesis involves autoimmune inflammation of the pericardium, which precipitates an acute inflammatory reaction and rapid fluid accumulation.

Conclusion

Pericarditis with cardiac tamponade and intermittent neutropenia may be rare manifestations of an Addisonian crisis.

Atrial fibrillation, end-stage renal disease and hemorrhagic pleural-pericarditis

Pericarditis is the most common pericardial disease found in clinical practice, with an incidence of acute pericarditis reported in 27.7 cases per 100,000 subjects per year. Hemodialysis in end stage renal disease (ESRD) is associated with frequent cardiovascular modifications, mostly because of the highly fluctuating levels of potassium, magnesium, ionized calcium, sodium and volume status. The risk of arrhythmias is increased and chronic atrial fibrillation (AF) can be found among approximately 14% of patients. The renal disease combined with arrhythmias increases the risk of systemic thromboembolism but also of bleeding events. Here we present the case of a male patient, with ESRD, recently diagnosed with intradialytic paroxysmal AF for which oral anticoagulation therapy is initiated, but it’s early complicated with hemorrhagic pleural-pericarditis.

Pericarditis after SARS-CoV-2 Infection: Another Pebble in the Mosaic of Long COVID?

With the emerging success of the COVID-19 vaccination programs, the incidence of acute COVID-19 will decrease. However, given the high number of people who contracted SARS-CoV-2 infection and recovered, we will be faced with a significant number of patients with persistent symptoms even months after their COVID-19 infection. In this setting, long COVID and its cardiovascular manifestations, including pericarditis, need to become a top priority for healthcare systems as a new chronic disease process. Concerning the relationship between COVID-19 and pericardial diseases, pericarditis appears to be common in the acute infection but rare in the postacute period, while small pericardial effusions may be relatively common in the postacute period of COVID-19. Here, we reported a series of 7 patients developing pericarditis after a median of 20 days from clinical and virological recovery from SARS-CoV-2 infection. We excluded specific identifiable causes of pericarditis, hence we speculate that these cases can be contextualized within the clinical spectrum of long COVID. All our patients were treated with a combination of colchicine and either ASA or NSAIDs, but four of them did not achieve a clinical response. When switched to glucocorticoids, these four patients recovered with no recurrence during drug tapering. Based on this observation and on the latency of pericarditis occurrence (a median of 20 days after a negative nasopharyngeal swab), could be suggested that post-COVID pericarditis may be linked to ongoing inflammation sustained by the persistence of viral nucleic acid without virus replication in the pericardium. Therefore, glucocorticoids may be a suitable treatment option in patients not responding or intolerant to conventional therapy and who require to counteract the pericardial inflammatory component rather than direct an acute viral injury to the pericardial tissue.

Disease and Economic Burden Associated with Recurrent Pericarditis in a Privately Insured United States Population

INTRODUCTION

Approximately 30% of patients with a first acute pericarditis episode experience a recurrence ≤ 18 months; ~ 15% experience multiple recurrences. This study assessed the recurrence and economic burden among patients with multiple recurrences.

METHODS

Adults with idiopathic pericarditis were identified in the OptumHealth Care Solutions, Inc., database (2007-2017). Recurrent pericarditis (RP) was defined as ≥ 2 episodes of care separated by > 28 days; multiple recurrences were defined as ≥ 2 recurrences.

RESULTS

Among 944 patients with RP, 375 (39.7%) experienced multiple recurrences and were propensity score-matched 1:1 to 375 patients without recurrence. Among patients with multiple recurrences, median disease duration (time from first episode to end of last recurrence, confirmed by a 1.5-year recurrence-free period) was 2.84 years. The multiple recurrences cohort had higher rates of hospitalizations per-patient-per-month (PPPM) than the no recurrence cohort (rate ratio [95% confidence interval (CI)] = 2.22 [1.35-3.65]). Mean total healthcare costs were significantly higher in the multiple recurrences versus no recurrence cohort ($2728 vs. $1568 PPPM, cost ratio [95% CI] = 1.74 [1.29-2.32]), mainly driven by higher hospitalization costs in the multiple recurrences cohort (mean: $1180 vs. $420 PPPM, cost ratio [95% CI] = 2.81 [1.80-4.66]). Mean work loss costs were higher in the multiple recurrences versus no recurrence cohort ($696 vs. $169 PPPM, cost ratio [95% CI] = 4.12 [1.64-9.61]). In patients with multiple recurrences, mean cost of the first episode was $19,189; subsequent recurrences ranged from $2089 to $7366 (second recurrence = $6222).

CONCLUSION

In conclusion, among patients with multiple pericarditis recurrences, disease symptoms persisted several years, and healthcare and work loss costs were further compounded in this subset of patients.

Epstein-Barr Virus DNA in Pericardial Effusion Causing Subacute Cardiac Tamponade

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Cardiac tamponade with hemodynamic compromise is an emergency, regardless of cause.

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The causes of pericardial disease vary widely with population and geography.

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Some causes of pericarditis require specific treatment and should be considered.

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EBV is a rarely described infectious cause of pericardial effusion.

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Both echocardiography and pericardiocentesis were very difficult in this case.

Use of Anakinra in steroid dependent recurrent pericarditis: a case report and review of literature

Non-steroidal anti-inflammatory drugs and colchicine are the cornerstone treatment for recurrent pericarditis. Corticosteroids are frequently used in patients with recurrent episodes of pericarditis. In patients with corticosteroid dependent and corticosteroid-resistant pericarditis, several steroid-sparing options like azathioprine, intravenous immunoglobulin (IVIG), and anakinra are being recently tried. In this article, we present the case of a 44-year-old male with recurrent pericarditis, who was successfully treated with anakinra.

Abbreviations: Non-steroidal anti-inflammatory drugs, NSAIDS; Aspirin, ASA; Erythrocyte sedimentation rate, ESR; Serum Protein Electrophoresis, SPEP; Magnetic Resonance Imaging, MRI; C-Reactive Protein, CRP; Aspartate Aminotransferase, AST; Alanine Aminotransferase, ALT; Idiopathic recurrent pericarditis, IRP; Intravenous Immunoglobulin, IVIG.

Impact of pericardial fluid glucose level and computed tomography attenuation values on diagnosis of malignancy-related pericardial effusion

Background

We evaluated malignancy according to the characteristics of pericardial fluid in symptomatic Japanese patients undergoing pericardiocentesis and computed tomography (CT).

Methods

This was a retrospective, single-center, observational study of 125 symptomatic patients undergoing pericardiocentesis. The patients were classified into two groups: a malignancy group and a non-malignancy group, according to the primary disease and cytology of the pericardial effusion (PE). We compared the pericardial fluid sample and CT measurements between both groups.

Results

All patients were diagnosed as having exudative PE by Light’s criteria. PE with malignant cells was demonstrated in 76.8% of the malignancy group patients. Pericardial to serum lactate dehydrogenase (LDH) ratio > 0.6, as one of Light’s criteria, was associated with malignancy (p = 0.017). Lower serum brain natriuretic peptide (BNP) concentration was also associated with malignancy (BNP: 126.9 ± 89.8 pg/ml vs 409.2 ± 97.7 pg/ml, malignancy vs non-malignancy groups, respectively; p = 0.037). A significant difference was observed in pericardial fluid glucose level between the malignancy and non-malignancy groups (pericardial fluid glucose: 78.24 ± 48.29 mg/dl vs 98.41 ± 44.85, respectively; p = 0.048). Moreover, CT attenuation values (Hounsfield units (HU)) tended to be higher in the malignancy group vs the non-malignancy group (22.7 [interquartile range (IQR), 17.4–26.0] vs 17.4 [IQR, 13.7–26.4], respectively; p = 0.08). The sensitivity and specificity of pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were 40.9% and 89.6%, respectively, in the malignancy group. The positive- and negative predictive values of pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were 85.7% and 50.0%, respectively, in the malignancy group. Pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were cutoff values associated with malignancy (p = 0.012).

Conclusions

Lower pericardial fluid glucose level with higher CT attenuation values may suggest malignancy-related PE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02091-6.

Acute pericarditis: Update on diagnosis and management

Acute pericarditis accounts for ∼5% of presentations with acute chest pain. Tuberculosis is an important cause in the developing world, however, in the UK and other developed settings, most cases are idiopathic/viral in origin. Non-steroidal anti-inflammatory drugs (NSAIDs) remain the cornerstone of treatment. At least one in four patients are at risk of recurrence. The addition of 3 months of colchicine can more than halve the risk of this (number needed to treat = four). Low-dose steroids can be helpful second-line agents for managing recurrences as adjuncts to NSAIDs and colchicine but should not be used as first-line agents. For patients failing this approach and/or dependent on corticosteroids, the interleukin-1β antagonist anakinra is a promising option, and for the few patients who are refractory to medical therapy, surgical pericardiectomy can be considered. The long-term prognosis is good with <0.5% risk of constriction for patients with idiopathic acute pericarditis.

Cardiac Tamponade Secondary to Influenza B Infection

Every year, Influenza infection contributes to significant morbidity and mortality carrying a huge economic burden. Extra-pulmonary manifestations are increasingly being recognized. We present a 29-year-old woman with acute pericarditis and cardiac tamponade requiring emergent pericardiocentesis secondary to Influenza B infection. Although very rare in relation to Influenza B infection, the pericardial disease can occur during the acute infection or as a post-viral syndrome. Considering pericardial disease in patients with chest pain and any viral infection may facilitate timely diagnosis and prevent unnecessary life-threatening complications.

Pericardial Involvement in Cancer

Despite the monumental advances in the diagnoses and therapeutics of malignancy, several cancer patients have presented with pericardial involvement, including acute pericarditis, constrictive pericarditis, and pericardial effusion. Multiple factors can contribute to acute pericarditis, including direct metastasis to the heart, pericardial hemorrhage, infections due to immunosuppression, and cancer therapies that include chemotherapy, immunotherapy, and radiation. Pericardial effusion, either due to cancer invasion or cancer treatment, is one of the most common incidental findings in cancer patients, which significantly worsens morbidity and mortality. If left untreated, pericardial effusion is known to cause complications such as pericardial tamponade. Constrictive pericarditis can be due to radiation exposure, chemotherapy, or is a sequela of a previous episode of acute pericarditis. In conclusion, early detection, prompt treatment, and understanding of pericardial diseases are necessary to help improve the quality of life of cancer patients, and we aim to summarize the knowledge of pericardial involvement in patients with cancer.

Recurrent pericarditis: an update on diagnosis and management

Recurrent pericarditis is a true challenge for clinicians, especially when the patient becomes unresponsive or not tolerant to conventional treatments. An accurate diagnosis of recurrent pericarditis, possibly supported by advanced imaging tools, is critical to provide timely and appropriate treatment of symptoms and prevention of further episodes. The incessant research on the inflammatory pathways underlying cardiovascular diseases, led recently to the assessment of anti interleukin-1 agents in the setting of recurrent pericarditis. This review will focus on the diagnostic assessment of recurrent pericarditis, along with the most modern therapeutic advances in this field. Bibliographic databases were searched (MEDLINE/PubMed, BioMed Central, the Cochrane Collaboration Database of Randomized Trials, Scopus, ClinicalTrials.gov, EMBASE, Google Scholar) using the terms "recurrent pericarditis" AND "diagnosis" OR "treatment" OR "IL-1" OR "inflammation".

Associated Pleural and Pericardial Effusions: An Extensive Differential Explored

Concurrent pleural and pericardial effusions are not an unusual finding, but their differential diagnosis remains uncertain. Medline-based review identified an extensive list of infectious, inflammatory, neoplastic, iatrogenic, and myriad other etiologies. A single retrospective study had addressed this presentation. Several principles of a diagnostic workup are suggested, acknowledging that a significant minority of patients may not require a comprehensive workup and remain 'idiopathic'.

Recognizing Cutibacterium acnes as a cause of infectious pericarditis: A case report and review of literature

Cutibacterium acnes is an anaerobic bacterium commonly thought of as a culture contaminant rather than a pathogen. We present a case of Cutibacterium acnes pericarditis in a 22-year-old immunocompetent woman managed with surgical pericardial window and a 4-week course of penicillin G and review related literature on Cutibacterium acnes pericarditis.

Responses to Treatment According to the Cytokine Profiles of Pericardial Effusion in Two Children with Idiopathic Pericarditis

Acute pericarditis is inflammation of the pericardium with or without pericardial effusion. In the pediatric population, most patients with acute pericarditis are diagnosed with idiopathic pericarditis. Herein, we present two children with idiopathic pericarditis who underwent immunological assessment of pericardial effusion for the first time. Both patients showed equally high levels of interleukin-6 in the pericardial effusion. However, they had different treatment responses, in accordance with the pericardial effusion and serum interleukin-10 concentrations. Our present cases suggest that interleukin-10 may be associated with the response to anti-inflammatory therapy in idiopathic acute pericarditis.

Spodick's Sign: A Case Report and Review of Literature

Acute pericarditis is commonly diagnosed in patients who present with chest pain. Accurate diagnosis of acute pericarditis is essential because of its relative similarity to ST-elevation myocardial infarction (STEMI) in both clinical presentation and electrocardiogram (EKG) changes. Additionally, troponin elevation is occasionally seen in acute pericarditis due to myocardial involvement (myopericarditis), which makes accurate diagnosis more challenging. A 12-lead EKG remains the most useful diagnostic test in differentiating acute pericarditis from STEMI. Spodick's sign is a less recognized electrocardiographic feature of acute pericarditis and is frequently overlooked by clinicians. We present a case of a 52-year-old male who initially presented with acute onset substernal chest pain. His EKG revealed diffuse subtle ST elevation and downsloping TP segment (Spodick's sign). A coronary angiogram demonstrated normal coronaries which eliminated the possibility of coronary artery disease. In this article, we will discuss how to differentiate between acute pericarditis and myocardial infarction, with a focus on Spodick's sign, amongst other EKG findings suggestive of pericarditis.