Differentiating COVID-19-associated pericarditis from other diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]

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.

Diseases	Symptoms			Physical Examination			Diagnostic tests				Other Findings
	Dyspnea on Exertion	Chest Pain	Hemoptysis	Fever	Tachypnea	Tachycardia	Chest X-ray	ECG	Echocardiography	CT scan and CMR
COVID-19-associated pericarditis	✔	✔ (relieves on sitting or leaning forward)	-	✔	✔	-	Normal limits in acute pericarditis. Enlarged cardiac silhouette in cardiac tamponade.	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)	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	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.	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.
COVID-19-associated myocarditis	✔	✔	-	✔	✔	✔	Pericardial effusion may be detectable	Non-specific:may show nonspecific ST-T abnormalities, sinus tachycardia and conduction abnormalities (such as bundle-branch blocks or atrioventricular conduction delays)	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.	CMR: T2-weighted edema imaging shows the presence of “acute myocardial inflammation”. "Late gadolinium enhancement (LGE) imaging” can demonstrate myocardial damage.	Increased cardiac troponin level
COVID-19-associated myocardial infarction	✔	✔	-	✔(Low-grade)	✔/-	✔/-	No specific X-ray findings	ST elevation MI (STEMI) Non-ST elevation MI (NSTEMI) or Non Q wave	Localized wall motion abnormalities Diffuse hypokinesia Left ventricular ejection fraction was lower than 50% in about 61% of the individuals.	-	Increased cardiac troponin levels
COVID-19-associated heart failure	✔	-	✔	-	✔	✔	Cardiomegaly Pulmonary edema (interstitial, alveolar)	Left ventricular hypertrophy Low-voltage QRS Non-specific ST-T change	Systoloic dysfunction (in HFrEF) Diastoic dysfunction (in HFpEF) COVID-19-associated stress cardiomyopathy (apical ballooning)	CT: Cardiomegaly, Pulmonary edema CMR: Signs of underlying myocarditis may be seen.	Increased NT-proBNP and cardiac troponins levels
COVID-19-associated pneumonia	✔	✔ (Pleuritic)	✔	✔ (Usually high)	✔	✔	Lobar Consolidation	Prolonged PR interval Transient T wave inversions	-	CT: Lobar Consolidation	Increased inflammatory markers, including ESR, hs-CRP
COVID-19-associated acute respiratory distress syndrome	✔	-	✔	✔	✔	✔	Bilateral ground-glass opacities	-	Signs of RV dysfunction/RV dilatation may be seen.	CT: Bilateral ground-glass opacities	-
COVID-19-associated pulmonary embolism	✔ (Usually sudden-onset)	✔ (Pleuritic)	✔ (If massive PE)	✔ (Low-grade)	✔	✔	May show Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign	Non-specific:may show S1Q3T3 pattern	May show signs of RV strain, RV dilatation, RV dysfunction (if large PE)	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)	Increased D-dimer, fibrinogen, and fibrin degradation products levels May have symptoms and/or signs of accompanying DVT

References