Diagnosis and treatment of pericarditis

Cardiac tamponade and adrenal insufficiency due to pembrolizumab: a case report

Introduction

Patients who receive or have received anti-programmed cell-death-1 (PD-1) monoclonal antibodies can develop immune-related adverse events due to activation of the immune system.

Case presentation

We report a case of a patient who received pembrolizumab and presented with cardiac tamponade. Despite pericardial drainage, she persisted with refractory arterial hypotension due to secondary adrenal insufficiency. After initiating corticosteroid therapy, the patient recovered successfully.

Discussion

The association of pericarditis, hypophysitis and thyroid dysfunction support the diagnosis of a life-threatening immune-related adverse event due to pembrolizumab. In case of immune-related adverse events secondary to anti-PD-1 monoclonal antibodies, corticosteroid therapy should be promptly initiated in order to avoid major complications.

A Review of Interleukin-1 in Heart Disease: Where Do We Stand Today?

Cardiovascular diseases are the leading cause of death worldwide. Research in the last two decades has emphasized the inflammatory process as a key component in the pathogenesis of many of them. The Interleukin-1 family is a pivotal element of inflammation and has been well studied as a therapeutic target in various inflammatory states. Recent trials have explored the effect of Interleukin-1 blockade in cardiovascular diseases and initial evidence of the relevance of such treatment in this field of medicine accumulate. This review will describe the role of Interleukin-1 in heart diseases and the potential therapeutic effect of its blockade in such diseases.

Acute Pericarditis Occurring Three Days after Intravesical Instillation of Mitomycin C after Transurethral Bladder Tumor Resection in a 64-Year-Old Woman

We present a 64-year-old woman who developed symptoms of acute pericarditis three days after undergoing intravesical instillation of mitomycin C following transurethral bladder tumor resection. Mitomycin C is a chemotherapeutic agent which acts by alkylation of DNA and is known to be cardiotoxic when systemically administered. Despite classic pericarditis symptoms, the patient underwent an urgent coronary angiogram due to elevated cardiac troponin I level, EKG changes, and wall motion abnormalities on her echocardiogram. During her angiogram, it was found that she had multiple stenotic coronary artery lesions, with no acute total coronary occlusions, and percutaneous coronary intervention (PCI) was done with placement of a single drug-eluting stent for a 95% stenotic lesion in the left anterior descending artery. The patient was discharged after an uneventful hospitalization on dual antiplatelet therapy with aspirin and prasugrel, and colchicine for pericarditis. It is likely that the patient's presentation was the result of a perimyocardial inflammatory process secondary to intravesically administered mitomycin C, rather than an acute coronary syndrome. While the pathophysiological basis of cardiotoxicity of systemically administered mitomycin C is well documented, more studies are needed to determine whether intravesical MMC may cause cardiotoxicity.

New Insights into Pericarditis: Mechanisms of Injury and Therapeutic Targets

PURPOSE OF REVIEW

This review article aims to provide a contemporary insight into the pathophysiological mechanisms of and therapeutic targets for pericarditis, drawing distinction between autoinflammatory and autoimmune pericarditis.

RECENT FINDINGS

Recent research has focused on the distinction between autoinflammatory and autoimmune pericarditis. In autoinflammatory pericarditis, viruses can activate the sensor molecule of the inflammasome, which results in downstream release of cytokines, such as interleukin-1, that recruit neutrophils and macrophages to the site of injury. Conversely, in autoimmune pericarditis, a type I interferon signature predominates, and pericardial manifestations coincide with the severity of the underlying systemic autoimmune disease. In addition, autoimmune pericarditis can also develop after cardiac injury syndromes. With either type of pericarditis, imaging can help stage the inflammatory state. Prominent pericardial delayed hyperenhancement on magnetic resonance imaging suggests ongoing inflammation whereas calcium on computed tomography suggests a completed inflammatory cascade. In patients with ongoing pericarditis, treatments that converge on the inflammasome, such as colchicine and anakinra, have proved effective in recurrent autoinflammatory pericarditis, though further clinical trials with anakinra are warranted. An improved understanding of the pathophysiological mechanisms of pericarditis helps unravel effective therapeutic targets for this condition.

Successful treatment of community-acquired methicillin-resistant Staphylococcus aureus purulent myopericarditis

A previously healthy 48-year-old active duty man, who had been treated for an elbow abscess 3 weeks earlier, presented to an emergency department in Bahrain with tachycardia, pericardial friction rub and jugular venous distention. Cardiac tamponade was confirmed on transthoracic echocardiogram and he was taken for emergent pericardiocentesis. Pericardial fluid cultures grew community-acquired methicillin-resistant Staphylococcus aureus Despite ongoing treatment with intravenous vancomycin, he developed a recurrent fibrinous pericardial effusion and constrictive pericarditis requiring pericardiectomy. Though he initially did well postoperatively, he developed drug reaction with eosinophilia and systemic symptoms syndrome in response to vancomycin. He was transitioned to ceftaroline and started on high-dose steroids. He recovered during a week-long admission and was discharged home. Several weeks later at follow-up he was doing well and had resumed moderate intensity exercise.

Recurrent Pericarditis: Modern Approach in 2016

Recurrent pericarditis is one of the most troublesome complications of pericarditis occurring in about one third of patients with a previous attack of pericarditis. The pathogenesis is presumed to be autoimmune and/or autoinflammatory in most cases. The mainstay of therapy for recurrences is physical restriction and anti-inflammatory therapy based on aspirin or NSAID plus colchicine. Corticosteroids at low to moderate doses (e.g., prednisone 0.2 to 0.5 mg/kg/day) should be considered only after failure of aspirin/NSAID (and more than one of these drugs) or for specific indications (e.g., pregnancy, systemic inflammatory diseases on steroids, renal failure, concomitant oral anticoagulant therapy). One of the most challenging issues is how to cope with patients who have recurrences despite colchicine. A small subset of patients (about 5 %) may develop corticosteroid-dependence and colchicine resistance. Among the emerging treatments, the three most common and evidence-based therapies are based on azathioprine, human intravenous immunoglobulin (IVIG), and anakinra. After failure of all options of medical therapy or for those patients who do not tolerate medical therapy or have serious adverse events related to medical therapy, the last possible option is the surgical removal of the pericardium. Total or radical pericardiectomy is recommended in these cases in experienced centers performing this surgery. A stepwise approach is recommended starting from NSAID and colchicine, corticosteroid and colchicine, a combination of the three options (NSAID, colchicine and corticosteroids), then azathioprine, IVIG, or anakinra as last medical options before pericardiectomy.

Complicated Pericarditis: Understanding Risk Factors and Pathophysiology to Inform Imaging and Treatment

Most patients with acute pericarditis have a benign course and a good prognosis. However, a minority of patients develop complicated pericarditis, and the care of these patients is the focus of this review. Specifically, we address risk factors, multimodality imaging, pathophysiology, and novel treatments. The authors conclude that: 1) early high-dose corticosteroids, a lack of colchicine, and an elevated high-sensitivity C-reactive protein are associated with the development of complicated pericarditis; 2) in select cases, cardiovascular magnetic resonance imaging may aid in the assessment of pericardial inflammation and constriction; 3) given phenotypic similarities between recurrent idiopathic pericarditis and periodic fever syndromes, disorders of the inflammasome may contribute to relapsing attacks; and 4) therapies that target the inflammasome may lead to more durable remission and resolution. Finally, regarding future investigations, the authors discuss the potential of cardiovascular magnetic resonance to inform treatment duration and the need to compare steroid-sparing treatments to pericardiectomy.

Pericarditis as a Marker of Occult Cancer and a Prognostic Factor for Cancer Mortality

BACKGROUND

Pericarditis may be a serious complication of malignancy. Its significance as a first symptom of occult cancer and as a prognostic factor for cancer survival is unknown.

METHODS

Using Danish medical databases, we conducted a nationwide cohort study of all patients with a first-time diagnosis of pericarditis during 1994 to 2013. We excluded patients with previous cancer and followed up the remaining patients for subsequent cancer diagnosis until November 30, 2013. We calculated risks and standardized incidence ratios of cancer for patients with pericarditis compared with the general population. We assessed whether pericarditis predicts cancer survival by the Kaplan-Meier method and Cox regression using a matched comparison cohort of cancer patients without pericarditis.

RESULTS

Among 13 759 patients with acute pericarditis, 1550 subsequently were diagnosed with cancer during follow-up. The overall cancer standardized incidence ratio was 1.5 (95% confidence interval [CI], 1.4-1.5), driven predominantly by increased rates of lung, kidney, and bladder cancer, lymphoma, leukemia, and unspecified metastatic cancer. The <3-month cancer risk among patients with pericarditis was 2.7%, and the standardized incidence ratio was 12.4 (95% CI, 11.2-13.7). The 3- to <12-month standardized incidence ratio of cancer was 1.5 (95% CI, 1.2-1.7), subsequently decreasing to 1.1 (95% CI, 1.0-1.2). Three-month survival after the cancer diagnosis was 80% and 86% among those with and without pericarditis, respectively, and the hazard ratio was 1.5 (95% CI, 1.3-1.8). One-year survival was 65% and 70%, respectively, corresponding to a 3- to <12-month hazard ratio of 1.3 (95% CI, 1.1-1.5).

CONCLUSIONS

Pericarditis may be a marker of occult cancer and augurs increased mortality after a cancer diagnosis.

European Guidelines on Pericardial Diseases: a Focused Review of Novel Aspects

Pericardial diseases are not uncommon in daily clinical practice. The spectrum of these syndromes includes acute and chronic pericarditis, pericardial effusion, constrictive pericarditis, congenital defects, and neoplasms. The extent of the high-quality evidence on pericardial diseases has expanded significantly since the first international guidelines on pericardial disease management were published by the European Society of Cardiology in 2004. The clinical practice guidelines provide a useful reference for physicians in selecting the best management strategy for an individual patient by summarizing the current state of knowledge in a particular field. The new clinical guidelines on the diagnosis and management of pericardial diseases that have been published by the European Society of Cardiology in 2015 represent such a tool and focus on assisting the physicians in their daily clinical practice. The aim of this review is to outline and emphasize the most clinically relevant new aspects of the current guidelines as compared with its previous version published in 2004.

Recurrent pericarditis: a case report and literature review

BACKGROUND

Recurrence affects about 30% (20% to 50%) of patients within 18 months after the initial episode of acute pericarditis resulting in subsequent rehospitalizations. Bearing in mind high treatment costs of patients admitted to hospital with acute and recurrent pericarditis, there is a need to optimize the treatment of both of these conditions.

MATERIALS AND METHODS

We present a case of recurrent pericarditis. The first episode of pericarditis was diagnosed in 2006. Three months later the patient was hospitalized due to clinical symptoms suggesting recurrence of a past condition. Ten years after the initial episode of acute pericarditis the patient was hospitalized for the treatment of recurrent pericarditis. The search for etiology of the disease was unsuccessful, the patient received treatment with nonsteroidal anti-inflammatory drugs; empiric antimicrobial therapy was also administered.

RESULTS AND CONCLUSIONS

Acute pericarditis is the most common disease of the pericardium encountered in clinical practice. Colchicine has been demonstrated as a first-line drug to be added to conventional anti-inflammatory therapies in patients with a first episode of pericarditis or its recurrences in order to improve the response to therapy and reduce recurrences. Despite a large amount of new data, there are still several issues that require additional research and clarification, including the search for new individualized therapies, the best duration of treatment for patients with pericardial diseases, and optimization of patient follow-up in order to collect data on long-term outcomes that would allow shortening the duration of in-patient treatment and reduction of recurrences.

A Rare Case of Primary Meningococcal Myopericarditis in a 71-Year-Old Male

We describe a case of primary meningococcal C pericarditis with myocardial involvement in a 71-year-old male that is thus far the oldest patient with isolated meningococcal pericardial disease and only the third patient with primary meningococcal myopericarditis described in English literature. Our patient was successfully treated by full sternotomy and surgical drainage combined with intravenous ceftriaxone. Mild symptoms unresponsive to anti-inflammatory treatment and leukocytosis may guide clinicians towards the correct diagnosis. It is important to recognize this cause of pericarditis as the relatively mild clinical presentation may rapidly progress into tamponade and right-sided heart failure.

Recent advances in the management of pericardial diseases

Pericardial diseases are relatively common in clinical practice either as isolated diseases or part of an underlying or systemic disease. Recent advances in the diagnosis and treatment have greatly improved the clinical management and lead to consensus documents on multimodality imaging and new guidelines on the diagnosis and therapy of pericardial diseases. The aim of the present paper is to summarize available evidence in order to provide an updated and comprehensive review on the recent advances in the management of pericardial diseases.

Anticardiac Antibodies in Patients with Chronic Pericardial Effusion

Objectives. Chronic pericardial effusion may be challenging in terms of diagnosis and treatment. Specific laboratory parameters predicting the frequency and severity of recurrences after initial drainage of pericardial effusion are lacking. Materials and Methods. Pericardial fluid (PF) and serum (SE) samples from 30 patients with chronic pericardial effusion (PE) who underwent pericardiocentesis and pericardioscopically guided pericardial biopsy were compared with SE and PF samples from 26 control patients. The levels of antimyolemmal (AMLA) and antifibrillary antibodies (AFA) in PE and SE from patients with pericardial effusion as well as PF and SE from controls were determined and compared. Results. AMLAs and AFAs in PF and SE were significantly higher in patients with chronic pericardial effusion than in the control group (AMLAs: p = 0,01 for PF and p = 0,004 for serum; AFAs: p < 0,001 for PF and p = 0,003 for serum). Patients with recurrence of PE within 3 months after pericardiocentesis had significantly higher levels of AMLAs in SE (p = 0,029) than patients without recurrence of PE. Conclusions. The identification of elevated anticardiac antibodies in PE and SE indicates increased immunological reactivity in chronic pericardial effusion. High titer serum levels of AMLAs also correlate with recurrence of pericardial effusion.