View source for Differentiating COVID-19-associated pericarditis from other diseases

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[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/COVID-19-associated_pericarditis]]

{{CMG}}; {{AE}}{{MRV}}


==Overview==
COVID-19-associated pericarditis must be differentiated from other causes of dyspnea and chest pain, such as [[myocarditis]], [[heart failure]], [[acute coronary syndrome]], [[pneumonia]] and [[pulmonary embolism]] 

==Differential Diagnosis==

COVID-19-associated pericarditis must be differentiated from other causes of dyspnea and chest pain, such as [[myocarditis]], [[heart failure]], [[acute coronary syndrome]], [[pneumonia]] and [[pulmonary embolism]] 

<small>
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! colspan="3" |<small>Symptoms</small>
! colspan="3" |<small>Physical Examination</small>
! colspan="4" |<small>Diagnostic tests
! rowspan="2" |<small>Other Findings</small>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<small>Dyspnea on Exertion</small>
!<small>Chest Pain</small>
!<small>Hemoptysis</small>
!<small>Fever</small>
!<small>Tachypnea</small>
!<small>Tachycardia</small>
!<small>Chest X-ray</small>  
!<small>ECG</small>
!<small>Echocardiography</small>
!<small>CT scan and CMR</small> 
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated pericarditis]]
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔ (relieves on sitting or leaning forward)
| style="background: #F5F5F5; padding: 5px;" |- 
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |
*Normal limits in [[acute pericarditis]].
*Enlarged [[cardiac]] silhouette in [[cardiac tamponade]].
| style="background: #F5F5F5; padding: 5px;" | 
*[[ST elevation]] and [[PR depression]] are seen but these changes are not specific to COVID-19 pericarditis.
*Non-specific ST changes
*T wave inversion in the inferior leads (II, III and aVF)
| style="background: #F5F5F5; padding: 5px;" | 
*Small to moderate pericardial effusion.
*In the cases complicated by cardiac tamponade, findings included:
**Large pericardial effusion
**Right ventricular diastolic collapse
**Increased respiratory variation in peak E-wave mitral inflow velocity
**Dilated inferior vena cava
| style="background: #F5F5F5; padding: 5px;" | 
*CT: Pericardial effusion
*CMR: late gadolinium sequences done to rule out myocarditis showed extensive enhancement of the walls of the heart and the pericardium in two of the reported cases. 
| style="background: #F5F5F5; padding: 5px;" | 
*On physical exam, Pericardial friction rub may be heard; tachycardia, hypotension and distant heart sounds seen in cardiac tamponade 
*Increased cardiac [[troponin]] level, [[CK]] level; increase in [[inflammatory]] markers levels.
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated myocarditis]]
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |- 
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*[[Pericardial effusion]] may be detectable
| style="background: #F5F5F5; padding: 5px;" | 
* Non-specific:may show nonspecific ST-T abnormalities, [[sinus tachycardia]] and [[conduction abnormalities]] (such as [[bundle branch block|bundle-branch blocks]] or [[atrioventricular block|atrioventricular conduction delays]])
| style="background: #F5F5F5; padding: 5px;" | 
*Non-specific: In [[fulminant myocarditis]], cardiac chamber sizes are usually normal with an increased septal thickness (secondary to acute myocardial edema), whereas in acute [[myocarditis]] marked left [[ventricular]] dilation and normal wall thickness might be seen. 
*[[Pericardial effusion]] may be be seen.
| style="background: #F5F5F5; padding: 5px;" | 
*CMR: T2-weighted [[edema]] imaging shows the presence of “acute [[myocardial]] [[inflammation]]”. "Late gadolinium enhancement (LGE) imaging” can demonstrate [[myocardial]] damage. 
| style="background: #F5F5F5; padding: 5px;" | Increased cardiac [[troponin]] level
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated myocardial infarction]]
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |- 
| style="background: #F5F5F5; padding: 5px;" |✔(Low-grade) 
| style="background: #F5F5F5; padding: 5px;" |✔/- 
| style="background: #F5F5F5; padding: 5px;" |✔/-
| style="background: #F5F5F5; padding: 5px;" |
*No specific X-ray findings
| style="background: #F5F5F5; padding: 5px;" | 
*[[ST elevation MI]] ([[STEMI]])
*[[Non-ST elevation MI]] ([[NSTEMI]]) or Non Q wave
| style="background: #F5F5F5; padding: 5px;" | 
*Localized wall motion abnormalities
*Diffuse hypokinesia  
*Left ventricular [[ejection fraction]] was lower than 50% in about 61% of the individuals.
| style="background: #F5F5F5; padding: 5px;" | 
- 
| style="background: #F5F5F5; padding: 5px;" | Increased cardiac [[troponin]] levels
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated heart failure|COVID-19-associated heart failure]]
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |- 
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*[[Cardiomegaly]]
*[[Pulmonary edema]] (interstitial, alveolar)
| style="background: #F5F5F5; padding: 5px;" | 
*[[Left ventricular hypertrophy]]
*[[Low-voltage]] QRS
*Non-specific ST-T change
| style="background: #F5F5F5; padding: 5px;" | 
*Systoloic dysfunction (in HFrEF)
*Diastoic dysfunction (in HFpEF)
*[[COVID-19-associated stress cardiomyopathy|COVID-19-associated stress cardiomyopathy]] [[(apical ballooning)]]
| style="background: #F5F5F5; padding: 5px;" | 
*CT: [[Cardiomegaly]], [[Pulmonary edema]]
*CMR: Signs of underlying [[myocarditis]] may be seen.
| style="background: #F5F5F5; padding: 5px;" | Increased [[NT-proBNP]] and cardiac [[troponin]]s levels
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated pneumonia]]
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔ ([[Pleuritic]])
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔ (Usually high)
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*[[Lobar Consolidation]]
| style="background: #F5F5F5; padding: 5px;" | 
*Prolonged [[PR interval]]
*Transient [[T wave]] inversions
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | 
*CT: [[Lobar Consolidation]]
| style="background: #F5F5F5; padding: 5px;" | Increased [[inflammatory markers]], including [[ESR]], hs-[[CRP]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated acute respiratory distress syndrome|COVID-19-associated acute respiratory distress syndrome]]
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |-
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*Bilateral [[ground-glass opacities]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | 
*Signs of [[Right ventricle|RV]] dysfunction/[[Right ventricle|RV]] dilatation may be seen.
| style="background: #F5F5F5; padding: 5px;" | 
*CT: Bilateral [[ground-glass opacities]]
| style="background: #F5F5F5; padding: 5px;" | -
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[COVID-19-associated pulmonary embolism]]
| style="background: #F5F5F5; padding: 5px;" |✔ (Usually sudden-onset)
| style="background: #F5F5F5; padding: 5px;" |✔ ([[Pleuritic]])
| style="background: #F5F5F5; padding: 5px;" |✔ (If massive PE)
| style="background: #F5F5F5; padding: 5px;" |✔ (Low-grade)
| style="background: #F5F5F5; padding: 5px;" |✔ 
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*May show [[Fleischner sign]] (enlarged [[pulmonary artery]]), [[Hampton hump]], [[Westermark's sign]]
| style="background: #F5F5F5; padding: 5px;" | 
* Non-specific:may show [[S1Q3T3]] pattern
| style="background: #F5F5F5; padding: 5px;" | 
*May show signs of [[Right ventricle|RV]] strain, [[Right ventricle|RV]] dilatation, [[Right ventricle|RV]] dysfunction (if large PE)
| style="background: #F5F5F5; padding: 5px;" | 
*On CT angiography: Intra-luminal filling defect
*On MRI: Narrowing of involved vessel
*No contrast seen distal to obstruction
*Polo-mint sign (partial filling defect surrounded by contrast)
| style="background: #F5F5F5; padding: 5px;" | 
*Increased [[D-dimer]], [[fibrinogen]], and [[fibrin degradation products]] levels
*May have symptoms and/or signs of accompanying [[DVT]]
|}
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== References ==
{{reflist|2}}
[[Category:COVID-19]]