Early introduction of anakinra improves acute pericarditis and prevents tamponade in Staphylococcal sepsis

Interleukin-1 Blockers in Recurrent and Acute Pericarditis: State of the Art and Future Directions

Diseases of the pericardium encompass a spectrum of conditions, including acute and recurrent pericarditis, where inflammation plays a pivotal role in the pathogenesis and clinical manifestations. Anti-inflammatory therapy indeed forms the cornerstone of treating these conditions: NSAIDs, colchicine, and corticosteroids (as a second-line treatment) are recommended by current guidelines. However, these medications come with several contraindications and are not devoid of adverse effects. In recent years, there has been an increased focus on the role of the inflammasome and potential therapeutic targets. Recurrent pericarditis also shares numerous characteristics with other autoinflammatory diseases, in which interleukin-1 antagonists have already been employed with good efficacy and safety. The objective of this review is to summarize the available studies on the use of anti-IL-1 drugs both in acute and recurrent pericarditis.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

Rapid resolution of severe pericardial effusion using anakinra in a patient with COVID-19 vaccine-related acute pericarditis relapse: a case report

Background

Pericarditis, along with myocarditis, is being increasingly reported after the coronavirus disease 2019 (COVID-19) vaccine, but the best treatment strategy in this specific setting is still unclear.

Case summary

We report a case of acute pericarditis after the second dose of mRNA COVID-19 vaccine with recurrence of large pericardial effusion after a previous pericardiocentesis and anti-inflammatory drugs tapering. The patient was successfully treated with the recombinant interleukin-1 receptor antagonist anakinra, with full reabsorption of the pericardial effusion and an abrupt drop of the inflammatory markers within 72 h. The patient was discharged a few days later, with a further decrease of the inflammatory markers and no residual symptoms.

Discussion

Anakinra is being increasingly used in the treatment of recurrent pericarditis due to its capability to interrupt the autoinflammatory response leading to deleterious cytokine storms. On account of its high efficacy and rapid onset, it has been reported to rapidly reverse large inflammatory pericardial effusions. Pericarditis and myocarditis have been reported after the COVID-19 vaccine, but this is the first case of COVID-19 vaccine-related pericarditis and pericardial effusion successfully treated with anakinra, avoiding a second pericardiocentesis.