Diagnostic issues in the clinical management of pericarditis

Cardiovascular Manifestations of Human Monkeypox Virus: An Updated Review

Cardiovascular manifestations in human monkeypox virus (MPXV) infection has gained increasing recognition as significant complications with both social and clinical implications. Myocarditis, viral pericarditis, heart failure, and arrhythmias can occur, leading to adverse effects on individuals' health and quality of life. Understanding the detailed pathophysiology of these cardiovascular manifestations is essential for improved diagnosis and management. The social implications of these cardiovascular complications are multifaceted, ranging from public health concerns and the impact on individuals' quality of life to psychological distress and social stigma. Clinically, diagnosing, and managing these complications present challenges, requiring a multidisciplinary approach and specialized care. The burden on healthcare resources necessitates preparedness and resource allocation to effectively address these complications. We delve into the pathophysiological mechanisms involved, including viral-induced cardiac damage, immune response, and inflammatory processes. Additionally, we explore the types of cardiovascular manifestations and their clinical presentations. Addressing cardiovascular manifestations' social and clinical implications in MPXV infection requires a comprehensive approach involving healthcare professionals, public health authorities, and communities. By prioritizing research, enhancing diagnosis and treatment strategies, and promoting preventive measures, we can mitigate the impact of these complications, improve patient care, and protect public health.

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.

Frequency of Electrocardiographic Alterations and Pericardial Effusion in Patients With Uncomplicated Malaria

Studies have proposed that malaria may lead to electrocardiographic (ECG) changes and pericardial inflammation. We aimed to investigate the frequency of ECG alterations, determined by ECG and Holter monitoring, and pericardial effusion in patients with malaria infection. We performed a prospective observational study of adult patients with uncomplicated malaria in Amazonas, Brazil. Peripheral blood smears, ECG, and bedside echocardiography were conducted before antimalarial treatment and repeated at follow-up after completed treatment. We evaluated the diagnostic value of PR-segment depression, PR-segment elevation, and Spodick's sign for detecting pericardial effusion. A subset of patients underwent Holter monitoring at baseline. Among 98 cases of uncomplicated malaria (55% men; mean age 40 years; median parasite density 1,774/µl), 75 had Plasmodium vivax, 22 Plasmodium falciparum, and 1 had mixed infection. At baseline, 17% (n = 17) had PR-segment depression, 12% (n = 12) PR-segment elevation, 3% (n = 2) Spodick's sign, and the prevalence of pericardial effusion was 9% (n = 9). ECG alterations had sensitivities of 22% to 89% and specificities of 88% to 100% for detecting pericardial effusion at baseline. PR-segment depression had the best accuracy (sensitivity 89%, specificity 90%). Of the 25 patients, 4 patients who did not have pericardial effusion, displayed nonsustained ventricular tachycardia, determined by Holter monitoring (median duration 43 hours). Follow-up examination data were obtained for 71 patients (median 31 days), for whom PR-segment depression, elevation, and pericardial effusion had reduced significantly (p <0.05). In conclusion, our findings suggest that ECG alterations may be useful to detect pericardial effusion in malaria and that these findings decrease after completed antimalarial treatment.

Cardiac involvement in hydrocarbon inhalant toxicity — role of cardiac magnetic resonance imaging: A case report

BACKGROUND

We report a patient who was diagnosed with toxic myopericarditis secondary to hydrocarbon abuse using cardiac magnetic resonance imaging (CMR).

CASE SUMMARY

A 25-year-old male presented to emergency department with chest pain for 3 d. Patient also reported sniffing hydrocarbon containing inhalant for the last 1 year. Labs showed elevated troponin and electrocardiography was suggestive of acute pericarditis. Echocardiogram showed left ventricular (LV) ejection fraction (EF) of 40%. Given patient’s troponin elevation and reduced EF, cardiac catheterization was performed which showed normal coronaries. CMR was performed for myocardial infarction with non-obstructive coronary arteries evaluation. CMR showed borderline LV function with edema in mid and apical LV suggestive of myocarditis.

CONCLUSION

CMR can be used to diagnose toxic myopericarditis secondary to hydrocarbon abuse.

The utilization of advance telemetry to investigate critical physiological parameters including electroencephalography in cynomolgus macaques following aerosol challenge with eastern equine encephalitis virus

Most alphaviruses are mosquito-borne and can cause severe disease in humans and domesticated animals. In North America, eastern equine encephalitis virus (EEEV) is an important human pathogen with case fatality rates of 30–90%. Currently, there are no therapeutics or vaccines to treat and/or prevent human infection. One critical impediment in countermeasure development is the lack of insight into clinically relevant parameters in a susceptible animal model. This study examined the disease course of EEEV in a cynomolgus macaque model utilizing advanced telemetry technology to continuously and simultaneously measure temperature, respiration, activity, heart rate, blood pressure, electrocardiogram (ECG), and electroencephalography (EEG) following an aerosol challenge at 7.0 log₁₀ PFU. Following challenge, all parameters were rapidly and substantially altered with peak alterations from baseline ranged as follows: temperature (+3.0–4.2°C), respiration rate (+56–128%), activity (-15-76% daytime and +5–22% nighttime), heart rate (+67–190%), systolic (+44–67%) and diastolic blood pressure (+45–80%). Cardiac abnormalities comprised of alterations in QRS and PR duration, QTc Bazett, T wave morphology, amplitude of the QRS complex, and sinoatrial arrest. An unexpected finding of the study was the first documented evidence of a critical cardiac event as an immediate cause of euthanasia in one NHP. All brain waves were rapidly (~12–24 hpi) and profoundly altered with increases of up to 6,800% and severe diffuse slowing of all waves with decreases of ~99%. Lastly, all NHPs exhibited disruption of the circadian rhythm, sleep, and food/fluid intake. Accordingly, all NHPs met the euthanasia criteria by ~106–140 hpi. This is the first of its kind study utilizing state of the art telemetry to investigate multiple clinical parameters relevant to human EEEV infection in a susceptible cynomolgus macaque model. The study provides critical insights into EEEV pathogenesis and the parameters identified will improve animal model development to facilitate rapid evaluation of vaccines and therapeutics.

In North America, EEEV causes the most severe mosquito-borne disease in humans highlighted by fatal encephalitis and permeant debilitating neurological sequelae in survivors. The first confirmed human cases were reported more than 80 years ago and since then multiple sporadic outbreaks have occurred including one of the largest in 2019. Unfortunately, most human infections are diagnosed at the on-set of severe neurological symptoms and consequently a detailed disease course in humans is lacking. This gap in knowledge is a significant obstacle in the development of appropriate animal models to evaluate countermeasures. Here, we performed a cutting-edge study by utilizing a new telemetry technology to understand the course of EEEV infection in a susceptible macaque model by measuring multiple physiological parameters relevant to human disease. Our study demonstrates that the infection rapidly produces considerable alterations in many critical parameters including the electrical activity of the heart and the brain leading to severe disease. The study also highlights the extraordinary potential of new telemetry technology to develop the next generation of animal models to comprehensively investigate pathogenesis as well as evaluate countermeasures to treat and/or prevent EEEV disease.

A 70-Year-Old Man With Conspicuous Thigh Pain and ST-Segment Elevations

CASE PRESENTATION

A 70-year-old man presented to the ED with sudden onset of left thigh pain followed by transient chest discomfort. His history included cerebrovascular disease, hypertension, and cocaine and methamphetamine use. Physical examination revealed an uncomfortable male subject with a temperature of 37 °C, heart rate of 129 beats/min, BP of 130/65 mm Hg, and 98% oxygen saturation on room air. There was point tenderness in the left lateral thigh without erythema, swelling, or overlying skin changes. His cardiac examination revealed an irregular tachycardia at 129 beats/min and normal first and second heart sounds without murmurs, gallops, or rubs. The remainder of the examination was unremarkable.

Role of advanced imaging in COVID-19 cardiovascular complications

Clinical manifestations of COVID-19 patients are dominated by respiratory symptoms, but cardiac complications are commonly observed and associated with increased morbidity and mortality. Underlying pathological mechanisms of cardiac injury are still not entirely elucidated, likely depending on a combination of direct viral damage with an uncontrolled immune activation. Cardiac involvement in these patients ranges from a subtle myocardial injury to cardiogenic shock. Advanced cardiac imaging plays a key role in discriminating the broad spectrum of differential diagnoses. Present article aims to review the value of advanced multimodality imaging in patients with suspected SARS-CoV-2-related cardiovascular involvement and its essential role in risk stratification and tailored treatment strategies. Based on our experience, we also sought to suggest possible diagnostic algorithms for the rationale utilization of advanced imaging tools, such as cardiac CT and CMR, avoiding unnecessary examinations and diagnostic delays.

Investigating the Usefulness of European Society of Cardiology Guidelines for Hospitalization in Acute Pericarditis at a Single Tertiary Center

Background The European Society of Cardiology (ESC) guidelines for the diagnosis and management of pericardial diseases identify predictive factors of poor prognosis and advise either in favor or against hospitalization accordingly. We aim to evaluate the adequacy of hospitalization criteria in a cohort of patients presenting to the emergency department (ED) with acute pericarditis. Methods Retrospective analysis of patients admitted to ED with acute pericarditis, from 2009 to 2019. During ED stay, all patients were evaluated by a cardiologist who decided if the patient was to be discharged or hospitalized. Hospitalized and discharged patients were compared regarding the primary outcome, defined by a composite of: the need for pericardiocentesis and/or cardiac surgery, pericarditis recurrence, and all-cause death. The clinical decision was then counterpoised with ESC guidelines. Results A total of 192 patients were included in the analysis (median age 44.5 years old, 83.3% male) of which 87 (45.5%) were hospitalized. A total of 25% registered the primary outcome, mainly due to acute pericarditis recurrence, occurring in 21.9%. Predictors of recurrence were: glucocorticoid therapy (Odds Ratio [OR]=11.93, 95% Confidence Inirtval [CI] 3.13-45.5, p<0.001), fever at admission (OR=2.67, 95% CI 1.29-5.49, p=0.008), immunosuppression (OR=4.03, 95% CI 1.280-12.659, p=0.017) and increased cardiothoracic index (OR 3.85, CI 95% 1.67-8.86, p=0.002). Regarding hospitalisation/discharge decision, the ESC guidelines were respected in 73.4% of the cases. However, no significant difference in the primary outcome was noted whether the ESC guidelines were respected or not (27.5% vs. 24.3%, p=0.707). Conclusions Discrepancy between current guidelines and the clinical decision did not translate into a different outcome.

Acute Pericarditis: Aetiologic Diagnosis and Practical Aspect of the Management

Pericarditis is an uncommon pathology that represents 0.1% of patients hospitalized for chest pain with a wide etiological spectrum and whose cause is uncommonly highlighted. In order to determine the incidence of specific acute microbiological or autoimmune pericarditis and identify subsets of patients with a higher incidence of specific etiologies; and analyze the conformity of the management of acute pericarditis according to the recommendations, a retrospective inclusion of all patients admitted to our hospital from January 2010 to December 2018 with the diagnosis of acute pericarditis was conducted. Data concerning clinical, paraclinical and treatment items were collected. Ninety-nine patients were included. Specific etiologic exams were completely conducted in 63.6% of the patients. There was no link between the decision to conduct etiology exams and the age, gender, a history of acute pericarditis or relapse. There was a trend between an elevated CRP and the realization of the kit. There was a statistically significant link between the achievement of etiologic exams and the presence of severity criteria or the presence of a pericardial effusion. An etiology was found in 52.4%, more frequently microbiological (viral and Mycoplasma pneumoniae). Approximately 85.9% of all patients were hospitalized. Treatment was in accordance with the recommendations in 76.8%. Despite the percentage of microbiological etiologies found, it does not impact the therapeutic strategy. The criteria for hospitalization must be better suited since half of those hospitalized after the european society of cardiology (ESC) 2015 recommendations had no need to be. However, monitoring after discharge is not clearly defined by learned societies.

Pericarditis - Clinical presentation and characteristics of a pediatric population

INTRODUCTION

Pericarditis is an inflammation of the pericardium. It may be infectious or secondary to a systemic disease. The aim of this study was to analyze the clinical findings, course, treatment and follow-up of children diagnosed with pericarditis at our center.

METHODS

We performed a retrospective analysis of all children admitted to our pediatric cardiology unit with pericarditis between 2003 and 2015. Patient characteristics were summarized using frequencies and percentages for categorical variables and medians with percentiles for continuous variables.

RESULTS

Fifty patients were analyzed (40 male, 10 female) with a median age of 14 years. The most common diagnosis was acute pericarditis (80%). Thirty-five patients (70%) presented with chest pain and 26% reported fever. Cardiomegaly was identified on chest X-ray in 11 patients (22%), 30 patients (60%) had an abnormal ECG and 44 patients (80%) had alterations on the transthoracic echocardiogram. In 17 cases (34%) there was myocardial involvement. Forty-eight percent of patients presented with infectious pericarditis and the pathologic agent was identified in half of them. Postpericardiotomy syndrome was diagnosed in five cases. The first-line therapy was aspirin in 50% of cases. Pericardiocentesis was performed in 12 patients. The median length of stay was nine days. There was symptom recurrence in seven children.

CONCLUSIONS

In this study, acute infectious pericarditis was the most common presentation and about one third of patients also had myocarditis. The symptom recurrence rate was not negligible and is probably related to the type of therapy employed.

Acute pericarditis: a review of current diagnostic and management guidelines

This review examined the relevance of chest pain, pericardial friction rub, pericardial effusion and ECG changes in regard to the diagnosis of acute pericarditis. It also assessed the evidence for the management and therapeutic guidelines, specifically nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids. Overall, there appears to be a lack of research into pericarditis. The bulk of high-quality research seems to have been carried out prior to the publication of the European Society of Cardiology guidelines of 2015. Diagnostically, the current combination of symptoms, clinical signs and investigations offer reasonable criteria for diagnosis, but they are not a gold standard. Research into its therapeutic treatment options is required to address the effects of specific nonsteroidal anti-inflammatory drugs (NSAIDs).

PR depression with multi‑lead ST elevation and ST depression in aVR: Is it always acute pericarditis?

The classic electrocardiographic (ECG) manifestation of stage I of acute pericarditis is diffuse ST elevation and PR depression with ST depression in lead aVR. One of the most common conditions, that is often confused with acute pericarditis, is the benign diffuse ST elevation, termed "early repolarization with ST elevation" (ERSTE). ERSTE often presents with diffuse ST elevation in the inferior and anterolateral leads, with or without terminal QRS notching or slurring. As ERSTE often presents with ST elevation in leads I and II, frequently there is concomitant ST depression in lead aVR, similar to the acute pericarditis ECG pattern. Moreover, PR depression in the inferior leads and/or PR elevation in lead aVR is often seen. Here we describe four patients with ERSTE, all had ST elevation in II with either ST elevation or isoelectric ST in lead I and concomitant ST depression in aVR. Two also had PR depression in the inferior leads. None of the patients had clinical symptoms or signs of acute pericarditis. In conclusion, diffuse ST elevation in the inferolateral leads associated with ST depression in aVR and even with PR segment depression is commonly found in ERSTE and should not be considered as pathognomonic of only acute pericarditis.

Cardiovascular Oncologic Emergencies

Oncologic emergencies can present either as a progression of a known cancer or as the initial presentation of a previously undiagnosed cancer. In most of these situations, a very high degree of suspicion is required to allow prompt assessment, diagnosis, and treatment. In this article, we review the presentation and management of cardiovascular oncologic emergencies from primary and metastatic tumors of the heart and complications such as pericardial tamponade, superior vena cava syndrome, and hyperviscosity syndrome. We have included the cardiovascular complications from radiation therapy, chemotherapeutic agents, and biologic agents used in modern cancer treatment.

Pharmacotherapy update of acute idiopathic pericarditis

Idiopathic (viral) pericarditis is the most common form of pericardial disease in the Western world. Despite the combination of colchicine and nonsteroidal antiinflammatory drugs (NSAIDs) plus aspirin (ASA), considered first-line therapy, the incidence of recurrent pericarditis is ~20-30%. In addition, secondary recurrence without optimal first-line therapy is ~50%. This is due to the many clinical challenges, such as inappropriate NSAID/ASA duration of therapy, the use of corticosteroid therapy, contraindications or intolerances to therapy, adverse effects, and issues related to adherence. This review describes contemporary pharmacotherapeutic management of idiopathic (viral) pericarditis, with a particular emphasis on the role of colchicine. Emerging therapies and management strategies, such as high-sensitivity C-reactive protein-guided therapy and novel immunotherapies, are also reviewed. Ultimately, understanding appropriate treatment will assist the clinician in helping decrease the risk of recurrent, incessant, and refractory pericarditis.

Long-term efficacy of interleukin-1 receptor antagonist (anakinra) in corticosteroid-dependent and colchicine-resistant recurrent pericarditis

OBJECTIVE

To evaluate the long-term response and safety of interleukin-1 receptor antagonist (anakinra) in recurrent pericarditis.

STUDY DESIGN

Fifteen patients (12 children, 3 adults) were enrolled in a multicenter retrospective study. All the patients were corticosteroid-dependent and 14 had received colchicine. Anakinra was given at 1-2 mg/kg/d. The primary outcome of the study was a reduction of at least 70% of disease flares after anakinra treatment compared with the pretreatment period. Secondary outcomes were: (1) number of complete or partial responders to anakinra and time for complete response; (2) number of patients who discontinued other ongoing treatments (non-steroidal anti-inflammatory drugs, corticosteroid, colchicine) and time needed for discontinuation; (3) number of relapses during continuous anakinra treatment; and (4) number of relapses during anakinra tapering or discontinuation.

RESULTS

All patients treated had a complete response within a few days and were able to rapidly withdraw concomitant treatments, including corticosteroids. During daily treatment, no patient had a relapse of the disease; 14 patients started tapering and 6 of them experienced a relapse, with a prompt response after anakinra reintroduction. Overall, after a median follow-up of 39 months (range 6-57), a 95% reduction of flares was observed compared with pretreatment period.

CONCLUSION

The long-term use of anakinra in monotherapy is associated with persistent control of recurrent pericarditis.

[Recurrent pericarditis as an initial manifestation of Wegener's granulomatosis]

Recurrent pericarditis occur in around a quarter of patients after a first episode of acute pericarditis. Most of the cases are idiopathic or viral pericarditis or post-pericardial injury syndromes. Recurrent pericarditis are most likely to occur in patients with known systemic lupus erythematosus or rheumatoid arthritis but are rare in other systemic auto-immune diseases. We report here an unusual case of a patient with a 5-year history of four acute myopericarditis revealing Wegener's granulomatosis. Clinicians should consider the possibility of Wegener's granulomatosis in case of recurrent pericarditis and look for features suggestive of granulomatous disease affecting the upper and lower respiratory tract. In this setting, antineutrophil cytoplasmic autoantibodies (ANCA) testing and/or biopsy of involved organs appear of particular interest to confirm the diagnosis.

Neoplastic pericarditis as the initial manifestation of a papillary thyroid carcinoma

Neoplastic pericarditis represents approximately 5%-7% of the cases with acute pericarditis and is rarely the initial manifestation of malignancy. The most common cause is lung cancer, followed by breast cancer, lymphomas, leukemia, and esophageal cancer. Neoplastic pericardial disease is extremely rare in thyroid cancer, especially as the first manifestation. Here, we present a papillary thyroid carcinoma that was manifested with pericarditis and cardiac tamponade in a 49-year-old female.

Prevention of recurrent pericarditis with colchicine in 2012

The most troublesome complication of acute pericarditis is recurrent pericardial inflammation, which occurs in 15%-32% of cases. The optimal method for prevention has not been fully established; accepted modalities include nonsteroidal anti-inflammatory drugs, corticosteroids, immunosuppressive agents, and pericardiectomy. Over the last years, objective clinical evidence has matured and clearly indicates the important role and beneficial clinical effect of colchicine therapy in preventing recurrent pericarditis caused by various etiologies. Colchicine-treated patients consistently display significantly fewer recurrences and longer symptom-free periods, and even when attacks occur, they are weaker and shorter in nature. Notably, pretreatment with corticosteroids substantially attenuates the efficacy of colchicine, causing significantly more recurrences and longer therapy periods. The safety profile seems superior to other drugs, such as corticosteroids and immunosuppressive drugs. Colchicine is a safe and effective modality for the treatment and prevention of recurrent pericarditis, especially as an adjunct to other modalities, because it provides a sustained benefit, superior to all current modalities.

Pericarditis: pathophysiology, diagnosis, and management

Pericarditis, the most common disease of the pericardium, may be isolated or a manifestation of a systemic disease. The etiology of pericarditis is varied and includes infectious (especially viral and tuberculosis) and noninfectious causes (autoimmune and autoinflammatory diseases, pericardial injury syndromes, and cancer [especially lung cancer, breast cancer, and lymphomas]). Most cases remain idiopathic with a conventional diagnostic evaluation. A targeted etiologic search should be directed to the most common cause on the basis of the patient's clinical background, epidemiologic issues, specific presentations, and high-risk features associated with specific etiologies or complications (fever higher than 38°C, subacute onset, large pericardial effusion, cardiac tamponade, lack of response to NSAIDs). The management of pericardial diseases is largely empiric because of the relative lack of randomized trials. NSAIDs are the mainstay of empiric anti-inflammatory therapy, with the possible addition of colchicine to prevent recurrences.