Pericarditis differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Pericarditis}}
[[Image:Home_logo1.png|right|250px|link=http://www.wikidoc.org/index.php/Pericarditis]]


{{CMG}}
{{CMG}}; {{AE}} {{HK}}{{Homa}}


'''For a full discussion of the differential diagnosis of [[chest pain]] click [[chest pain|here]]'''
'''For an expert algorithm that aids in the diagnosis of the cause of [[chest pain]] click [[chest pain|here]]'''
==Overview==
==Overview==
Signs and symptoms of [[pericarditis]] may be similar to several other conditions including [[myocardial infarction]], [[aortic dissection]] and [[pulmonary embolism]] which are life threatening and therefore it is important to differentiate them. Pain along the [[trapezius]] ridge, which is unresponsive to [[vasodilator]] therapy and varies with position are signs specific for pericarditis.
Pericarditis must be [[Differentiate|differentiated]] from [[diseases]] presenting with [[chest pain]], [[shortness of breath]] and [[tachypnea]] which include [[myocardial infarction]], [[pulmonary embolism]], [[congestive heart failure]], [[pneumonia]], [[vasculitis]], and [[chronic obstructive pulmonary disease]] ([[Chronic obstructive pulmonary disease|COPD]]). Manifestation of the pericarditis can help in differentiation from [[myocardial infarction]]. Moreover, other differential diagnosis include a[[Aortic stenosis|ortic stenosis]], [[coronary artery vasospasm]], [[esophageal rupture]], [[esophageal spasm]], [[esophagitis]],[[acute]] [[gastritis]], [[gastroesophageal reflux disease]], and [[peptic ulcer disease]] should be considered.
==Differentiating Pericarditis from other Diseases==


==Differentiating Pericarditis from other Conditions==
* Pericarditis must be [[Differentiate|differentiated]] from [[diseases]] presenting with [[chest pain]], [[shortness of breath]] and [[tachypnea]].
Several conditions, including life threatening conditions such as [[myocardial infarction]], [[aortic dissection]] and [[pulmonary embolism]] produce signs and symptoms that are similar to those produced by pericarditis. Although the following features are not 100% sensitive and/or specific in distinguishing the different causes of chest pain, they are useful guides:
**'''For a full discussion of the differential diagnosis of [[chest pain]] click [[chest pain|here]]'''
* Pain along the [[trapezius ridge]](s), is very characteristic of pericarditis. The pain of [[myocardial infarction]] tends to involve the anterior precordium with either no radiation or radiation to either the jaw or the left arm. 
**'''For an expert algorithm that aids in the diagnosis of the cause of [[chest pain]] click [[chest pain|here]]'''
* Unlike cardiac ischemia, the pain of pericarditis often lasts longer, and is unresponsive to vasodilator therapy.
* Pericarditis must be [[Differentiate|differentiated]] from [[myocardial infarction]] as an important cause of [[chest pain]].The [[Differentiate|differentiating]] features include:<ref name="mk">American College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. "Pericardial disease." p. 64. ISBN 978-934465-28-8 [http://www.acponline.org/products_services/mksap/15/complete.htm]</ref>
* Ischemic chest pain is often described as a sense of "heaviness", "vice like", "pressure like", or like "an elephant sitting on the chest".  The pain of pericarditis is often sharp and [[pleuritic]] (exacerbated by breathing in).
*Ischemic chest pain is generally not positional in nature whereas the pain of pericarditis is relieved by sitting up and bending forward and worsened by lying down (recumbent or [[supine]] position) or inspiration (taking a breath in)<ref name=mk>American College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. "Pericardial disease." p. 64. ISBN 978-934465-28-8 [http://www.acponline.org/products_services/mksap/15/complete.htm]</ref>  
* The EKG of pericarditis shows [[PR]] segment depression while the EKG of myocardial infarction does not (unless there is atrial infarction).
* The EKG of pericarditis shows [[ST elevation]] that does not necessarily follow the anatomic distribution of a single coronary artery.
* Other symptoms of pericarditis may include a viral prodrome including dry [[cough]], [[fever]], and [[fatigue]].
 
These differentiating features are summarized in the table below <ref name=mk />
:


{| class="wikitable"
{| class="wikitable"
Line 29: Line 19:
|-
|-
! scope="row" | Pain description
! scope="row" | Pain description
| Sharp, [[pleuritic]], retro-sternal (under the sternum) or left precordial (left chest) pain
| Sharp, [[pleuritic]], [[Sternal|retro-sternal]] (under the [[sternum]]) or left [[precordial]] (left [[chest]]) [[pain]].
| Crushing, pressure-like, heavy pain. Described as "elephant on the chest."
| Crushing, pressure-like, heavy [[pain]]. Described as "elephant on the [[chest]]".
|-
|-
! scope="row" | Radiation
! scope="row" | Radiation
| Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation.
|[[Pain]] [[Radiation|radiates]] to the [[Trapezius muscle|trapezius]] ridge (to the lowest portion of the [[scapula]] on the [[back]]) or no [[radiation]].
| Pain radiates to the jaw, or the left or arm, or does not radiate.
| Pain radiates to the [[jaw]], or the left or arm, or does not radiate.
|-
|-
! scope="row" | Exertion
! scope="row" | Exertion
| Does not change the pain
| Does not change the [[pain]]
| Can increase the pain
| Can increase the [[pain]]
|-
|-
! scope="row" | Position
! scope="row" | Position
| Pain is worse [[supine]] or upon inspiration (breathing in)
|[[Pain]] is worse [[supine]] or upon [[inspiration]] ([[breathing]] in)
| Not positional
| Not positional
|-
|-
! scope="row" | Onset/duration
! scope="row" | Onset/duration
| Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER
| Sudden [[pain]], that lasts for hours or sometimes days before a [[patient]] comes to the [[ER]]
| Sudden or chronically worsening pain that can come and go in [[paroxysm]]s or it can last for hours before the patient decides to come to the ER
| Sudden or [[Chronic (medicine)|chronically]] worsening pain that can come and go in [[paroxysm]]s or it can last for hours before the [[patient]] decides to come to the [[ER]]
|}
|}
===Differentiating pericarditis from other diseases on the basis of chest pain, shortness of breath, and tachypnea===


==Chest Pain Following Myocardial Infarction ==
The differentials include the following:<ref name="pmid24550636">{{cite journal |vauthors=Brenes-Salazar JA |title=Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era |journal=J Emerg Trauma Shock |volume=7 |issue=1 |pages=57–8 |year=2014 |pmid=24550636 |pmc=3912657 |doi=10.4103/0974-2700.125645 |url=}}</ref><ref name="urlCT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics">{{cite web |url=http://pubs.rsna.org/doi/full/10.1148/rg.245045008 |title=CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis &#124; RadioGraphics |format= |work= |accessdate=}}</ref><ref name="pmid23940438">{{cite journal |vauthors=Bĕlohlávek J, Dytrych V, Linhart A |title=Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism |journal=Exp Clin Cardiol |volume=18 |issue=2 |pages=129–38 |year=2013 |pmid=23940438 |pmc=3718593 |doi= |url=}}</ref><ref name="urlPulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022657/ |title=Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health |format= |work= |accessdate=}}</ref><ref name="pmid20118395">{{cite journal |vauthors=Ramani GV, Uber PA, Mehra MR |title=Chronic heart failure: contemporary diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=2 |pages=180–95 |year=2010 |pmid=20118395 |pmc=2813829 |doi=10.4065/mcp.2009.0494 |url=}}</ref><ref name="pmid18215495">{{cite journal |vauthors=Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL |title=Symptom distress and quality of life in patients with advanced congestive heart failure |journal=J Pain Symptom Manage |volume=35 |issue=6 |pages=594–603 |year=2008 |pmid=18215495 |pmc=2662445 |doi=10.1016/j.jpainsymman.2007.06.007 |url=}}</ref><ref name="pmid19168510">{{cite journal |vauthors=Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ |title=Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology |journal=Eur. J. Heart Fail. |volume=11 |issue=2 |pages=130–9 |year=2009 |pmid=19168510 |pmc=2639415 |doi=10.1093/eurjhf/hfn013 |url=}}</ref><ref name="pmid9465867">{{cite journal |vauthors=Takasugi JE, Godwin JD |title=Radiology of chronic obstructive pulmonary disease |journal=Radiol. Clin. North Am. |volume=36 |issue=1 |pages=29–55 |year=1998 |pmid=9465867 |doi= |url=}}</ref><ref name="pmid14651761">{{cite journal |vauthors=Wedzicha JA, Donaldson GC |title=Exacerbations of chronic obstructive pulmonary disease |journal=Respir Care |volume=48 |issue=12 |pages=1204–13; discussion 1213–5 |year=2003 |pmid=14651761 |doi= |url=}}</ref><ref name="pmid23833163">{{cite journal |vauthors=Nakawah MO, Hawkins C, Barbandi F |title=Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome |journal=J Am Board Fam Med |volume=26 |issue=4 |pages=470–7 |year=2013 |pmid=23833163 |doi=10.3122/jabfm.2013.04.120256 |url=}}</ref><ref name="pmid20511488">{{cite journal |vauthors=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK |title=Pericardial disease: diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=6 |pages=572–93 |year=2010 |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref><ref name="pmid23610095">{{cite journal |vauthors=Bogaert J, Francone M |title=Pericardial disease: value of CT and MR imaging |journal=Radiology |volume=267 |issue=2 |pages=340–56 |year=2013 |pmid=23610095 |doi=10.1148/radiol.13121059 |url=}}</ref><ref name="pmid11680112">{{cite journal |vauthors=Gharib AM, Stern EJ |title=Radiology of pneumonia |journal=Med. Clin. North Am. |volume=85 |issue=6 |pages=1461–91, x |year=2001 |pmid=11680112 |doi= |url=}}</ref><ref name="pmid23507061">{{cite journal |vauthors=Schmidt WA |title=Imaging in vasculitis |journal=Best Pract Res Clin Rheumatol |volume=27 |issue=1 |pages=107–18 |year=2013 |pmid=23507061 |doi=10.1016/j.berh.2013.01.001 |url=}}</ref><ref name="pmid16891436">{{cite journal |vauthors=Suresh E |title=Diagnostic approach to patients with suspected vasculitis |journal=Postgrad Med J |volume=82 |issue=970 |pages=483–8 |year=2006 |pmid=16891436 |pmc=2585712 |doi=10.1136/pgmj.2005.042648 |url=}}</ref><ref name="pmid123074">{{cite journal |vauthors=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW |title=The electrocardiogram in acute pulmonary embolism |journal=Prog Cardiovasc Dis |volume=17 |issue=4 |pages=247–57 |year=1975 |pmid=123074 |doi= |url=}}</ref><ref name="pmid23413894">{{cite journal |vauthors=Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML |title=Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease |journal=COPD |volume=10 |issue=1 |pages=62–71 |year=2013 |pmid=23413894 |doi=10.3109/15412555.2012.727918 |url=}}</ref><ref name="pmid23000104">{{cite journal |vauthors=Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H |title=Electrocardiogram in pneumonia |journal=Am. J. Cardiol. |volume=110 |issue=12 |pages=1836–40 |year=2012 |pmid=23000104 |doi=10.1016/j.amjcard.2012.08.019 |url=}}</ref><ref name="pmid26209947">{{cite journal |vauthors=Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S |title=Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis |journal=Int. J. Cardiol. |volume=199 |issue= |pages=170–9 |year=2015 |pmid=26209947 |doi=10.1016/j.ijcard.2015.06.087 |url=}}</ref><ref name="pmid20112390">{{cite journal |vauthors=Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S |title=Cardiac involvement in Churg-Strauss syndrome |journal=Arthritis Rheum. |volume=62 |issue=2 |pages=627–34 |year=2010 |pmid=20112390 |doi=10.1002/art.27263 |url=}}</ref><small>
It should be noted that [[ST elevation MI]] can also be associated with the subsequent development of pericarditis. In a patient with recurrent chest pain following [[acute MI]], one is often left wondering whether the [[chest pain]] is due to [[reocclusion]] of the culprit artery, or if it is due to the early development of [[pericarditis]], or if it occurs later, if it is due to [[Dressler's syndrome]]. Occlusion of the culprit artery or [[stent thrombosis]] should be associated with recurrent [[ST segment]] elevation in the appropriate anatomic ECG leads.


==Diagnosing Tuberculous Pericarditis: The Tygerberg Scoring System==
{|
Pericarditis caused by [[tuberculosis]] is difficult to diagnose, because definitive diagnosis requires culturing ''[[Mycobacterium tuberculosis]]'' from aspirated [[pericardium|pericardial]] fluid or pericardial [[Wiktionary:biopsy|biopsy]], which requires high technical skill and is often not diagnostic (the yield from culture is low even with optimum specimens). 
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! colspan="3" |<small>Diagnostic tests</small>
! colspan="3" |<small>Physical Examination</small>
| colspan="7" |<small>Symptoms
! colspan="1" rowspan="2" |<small>Past medical history</small>
! rowspan="2" |<small>Other Findings</small>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<small>CT scan and MRI</small>
!<small>EKG</small>
!<small>Chest X-ray</small>
!<small>Tachypnea</small>
!<small>Tachycardia</small>
!<small>Fever</small>
!<small>Chest Pain</small>
!<small>Hemoptysis</small>
!<small>Dyspnea on Exertion</small>
!<small>Wheezing</small>
!<small>Chest Tenderness</small>
!<small>Nasalopharyngeal Ulceration</small>
!<small>Carotid Bruit</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pulmonary embolism]]
| style="background: #F5F5F5; padding: 5px;" |
*On [[CT angiography]]:
** Intra-luminal filling defect
*On [[MRI]]:
** Narrowing of involved [[Blood vessel|vessel]]
** No contrast seen distal to [[obstruction]]
** Polo-mint sign (partial filling defect surrounded by contrast)
| style="background: #F5F5F5; padding: 5px;" |
*[[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
| style="background: #F5F5F5; padding: 5px;" |
*[[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]]
| 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;" |✔ (In case of massive PE)
| 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;" |
*Hypercoagulating conditions ([[Factor V Leiden]], [[thrombophilia]], [[deep vein thrombosis]], immobilization, [[malignancy]], [[pregnancy]])
| style="background: #F5F5F5; padding: 5px;" |
* May be associated with [[metabolic alkalosis]] and [[syncope]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Congestive heart failure]]
| style="background: #F5F5F5; padding: 5px;" |
*On [[Computed tomography|CT scan]]:
**[[Mediastinal lymphadenopathy]]
** Hazy [[mediastinal]] fat
*On [[Magnetic resonance imaging|MRI]]:
** Abnormality of [[cardiac]] chambers ([[Hypertrophy (medical)|hypertrophy]], dilation)
** Delayed enhancement [[MRI]] may help characterize the [[myocardial]] [[Tissue (biology)|tissue]] ([[fibrosis]])
** Late enhancement of contrast in conditions such as [[myocarditis]], [[sarcoidosis]], [[amyloidosis]], [[Anderson-Fabry disease|Anderson-Fabry]]'s disease, [[Chagas disease]])
| style="background: #F5F5F5; padding: 5px;" |
*Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
**[[S wave|S]]V1 or [[S wave|S]]V2 + [[R wave|R]]V5 or [[R wave|R]]V6 ≥3.5 mV
**Total [[QRS complex|QRS]] amplitude in each of the limb leads ≤0.8 mV
**[[R wave|R]]/[[S wave|S]] ratio <1 in lead V4
| style="background: #F5F5F5; padding: 5px;" |
*[[Cardiomegaly]]
| 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;" |  -
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" |
*Previous [[myocardial infarction]]
*[[Hypertension]] ([[Systemic hypertension|systemic]] and [[Pulmonary hypertension|pulmonary]])
*[[Cardiac arrhythmia|Cardiac arrythmias]]
*[[Viral]] infections ([[myocarditis]])
*[[Congenital heart disease|Congenital heart defects]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Right heart failure]] associated with:
**[[Hepatomegaly]]
**Positive hepato-jugular reflex
**Increased [[jugular venous pressure]]
**[[Peripheral edema]]
*[[Left heart failure]] associated with:
**[[Pulmonary edema]]
**Eventual [[right heart failure]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Percarditis]]
| style="background: #F5F5F5; padding: 5px;" |
*On contrast enhanced [[Computed tomography|CT scan]]:
**Enhancement of the [[pericardium]] (due to [[inflammation]])
**[[Pericardial effusion]]
**[[Pericardial calcification]]
*On [[gadolinium]]-enhanced fat-saturated [[Magnetic resonance imaging|T1-weighted MRI]]:
**[[Pericardial]] enhancement (due to [[inflammation]])
**[[Pericardial effusion]]
| style="background: #F5F5F5; padding: 5px;" |
*ST elevation
*PR depression
| style="background: #F5F5F5; padding: 5px;" |
*Large collection of fluid inside the pericardial sac (pericardial effusion)
*Calcification of pericardial sac
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔ (Low grade)
| style="background: #F5F5F5; padding: 5px;" |✔ (Relieved by sitting up and 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;" |  -
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" |
*Infections:
**[[Viral]] (Coxsackie virus, [[Herpes simplex virus|Herpes virus]], [[Mumps virus]], [[Human Immunodeficiency Virus (HIV)|HIV]])
**[[Bacteria]] ([[Mycobacterium tuberculosis]]-common in developing countries)
**[[Fungal]] ([[Histoplasmosis]])
*Idiopathic in a large number of cases
*[[Autoimmune]]
*[[Uremia]]
*[[Malignancy]]
*Previous [[myocardial infarction]]
| style="background: #F5F5F5; padding: 5px;" |
*May be clinically classified into:
**Acute (< 6 weeks)
**Sub-acute (6 weeks - 6 months)
**Chronic (> 6 months)
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumonia]]
| style="background: #F5F5F5; padding: 5px;" |
*On [[Computed tomography|CT scan]]: (not generally indicated)
**[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar pneumonia)
**Peribronchial [[nodules]] ([[bronchopneumonia]])
**[[Ground glass opacification on CT|Ground-glass opacity]] (GGO)
**[[Abscess]]
**[[Pleural effusion]]
**On [[MRI]]:
*Not indicated
| style="background: #F5F5F5; padding: 5px;" |
*Prolonged [[PR interval]]
*Transient [[T wave]] inversions
| style="background: #F5F5F5; padding: 5px;" |
*[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar [[pneumonia]])
*Peribronchial [[nodules]] (bronchopneumonia)
*Ground-glass opacity (GGO)
| 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;" |✔
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" |
*Ill-contact
*Travelling
*[[Smoking]]
*[[Diabetes mellitus|Diabetic]]
*Recent hospitalization
*[[Chronic obstructive pulmonary disease]]
| style="background: #F5F5F5; padding: 5px;" |
*Requires [[Sputum|sputum stain]] and culture for diagnosis
*[[Empiric therapy|Empiric management]] usually started before [[Culture collection|culture]] results
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Vasculitis]]
| style="background: #F5F5F5; padding: 5px;" |
*On [[Computed tomography|CT scan]]: ([[Takayasu's arteritis|Takayasu arteritis]])
**[[Blood vessel|Vessel]] wall thickening
**Luminal narrowing of [[pulmonary artery]]
**Masses or nodules ([[Anti-neutrophil cytoplasmic antibody|ANCA]]-associated granulomatous vasculitis)
*On [[Magnetic resonance imaging|MRI]]:


The [[Tygerberg score|Tygerberg scoring system]] is useful in ascertaining if pericarditis is due to tuberculosis. In order to calculate the score, the points are added together:  
Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Bundle branch block|Right or left bundle-branch block]] ([[Churg-Strauss syndrome]])
*[[Atrial fibrillation]] ([[Churg-Strauss syndrome]])
*Non-specific [[ST interval|ST segment]] and [[T wave]] changes
| style="background: #F5F5F5; padding: 5px;" |
*[[Nodule (medicine)|Nodules]]
*[[Cavitation]]
| 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;" |  -
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |✔
| style="background: #F5F5F5; padding: 5px;" |
*[[Takayasu's arteritis|Takayasu arteritis]] usually found in persons aged 4-60 years with a mean of 30
*[[Giant-cell arteritis]] usually occurrs in persons aged > 60 years
*[[Churg-Strauss syndrome]] may present with [[asthma]], [[sinusitis]], transient [[pulmonary]] infiltrates and neuropathy alongwith [[cardiac]] involvement
*Granulomatous vasculitides may present with [[nephritis]] and [[upper airway]] ([[nasopharyngeal]]) destruction
| style="background: #F5F5F5; padding: 5px;" |
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic obstructive pulmonary disease]] (COPD)
| style="background: #F5F5F5; padding: 5px;" |
*On [[Computed tomography|CT scan]]:
**[[Chronic bronchitis]] may show [[bronchial]] wall thickening, scarring with bronchovascular irregularity, [[fibrosis]]
**[[Emphysema]] may show [[alveolar]] septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe)
**Giant bubbles
*On [[MRI]]:
**Increased diameter of [[pulmonary arteries]]
**Peripheral [[pulmonary]] [[vasculature]] attentuation
**Loss of retrosternal airspace due to right ventricular enlargement
**Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung
| style="background: #F5F5F5; padding: 5px;" |
*[[Multifocal atrial tachycardia]] (atleast 3 distinct [[P waves|P wave]] morphologies)
| style="background: #F5F5F5; padding: 5px;" |
*Enlarged [[lung]] shadows ([[emphysema]])
*Flattening of [[diaphragm]] ([[emphysema]])
| 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;" |✔
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" |  -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
*[[Smoking]]
*[[Alpha 1-antitrypsin deficiency|Alpha-1 antitrypsin deficiency]]
*Increased [[sputum]] production ([[chronic bronchitis]])
*[[Cough]]
| style="background: #F5F5F5; padding: 5px;" |
*[[Alpha 1-antitrypsin deficiency|Alpha 1 antitrypsin deficiency]] may be associated with [[hepatomegaly]]
|}


* [[Night sweats]] (1 point),
* [[Weight loss]] (1 point),
* [[Fever]] (2 point),
* Serum globulin &gt; 40g/l (3 points),
* Blood total [[leukocyte count]] &lt;10 x 10<sup>9</sup>/l (3 points);


A total score of 6 or more is highly suggestive of tuberculous pericarditis.<ref>{{cite journal | author=Reuter H, Burgess L, van Vuuren W, Doubell A. | title=Diagnosing tuberculous pericarditis | journal=Q J Med | year=2006 | volume=99 | pages=827&ndash;39 | pmid=17121764 }}</ref> 
==Other differentials==
Pericarditis also resembles the following disorders and needs to be differentiated from them:
 
*[[Angina pectoris]]
*[[Aortic stenosis]]
*[[Coronary artery vasospasm]]
*[[Esophageal rupture]]
*[[Esophageal spasm]]
*[[Esophagitis]]
*[[Gastritis]], acute
*[[Gastroesophageal reflux disease]]
*[[Peptic ulcer disease]]


Pericardial fluid with an [[interferon-gamma|interferon-γ]] level greater than 50[[Wiktionary:picogram|pg]]/ml is highly specific for tuberculous pericarditis.


==References==
==References==
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[[Category:Cardiology]]
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[[Category:Emergency medicine]]
 
[[Category:Intensive care medicine]]
<br />
[[Category:Differential diagnosis]]
[[Category:Infectious disease]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Disease]]
[[Category:Overview complete]]

Latest revision as of 05:56, 4 March 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [3] Homa Najafi, M.D.[4]

Overview

Pericarditis must be differentiated from diseases presenting with chest pain, shortness of breath and tachypnea which include myocardial infarction, pulmonary embolism, congestive heart failure, pneumonia, vasculitis, and chronic obstructive pulmonary disease (COPD). Manifestation of the pericarditis can help in differentiation from myocardial infarction. Moreover, other differential diagnosis include aortic stenosis, coronary artery vasospasm, esophageal rupture, esophageal spasm, esophagitis,acute gastritis, gastroesophageal reflux disease, and peptic ulcer disease should be considered.

Differentiating Pericarditis from other Diseases

Characteristic/Parameter Pericarditis Myocardial infarction
Pain description Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain. Crushing, pressure-like, heavy pain. Described as "elephant on the chest".
Radiation Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation. Pain radiates to the jaw, or the left or arm, or does not radiate.
Exertion Does not change the pain Can increase the pain
Position Pain is worse supine or upon inspiration (breathing in) Not positional
Onset/duration Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours before the patient decides to come to the ER

Differentiating pericarditis from other diseases on the basis of chest pain, shortness of breath, and tachypnea

The differentials include the following:[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
CT scan and MRI EKG Chest X-ray Tachypnea Tachycardia Fever Chest Pain Hemoptysis Dyspnea on Exertion Wheezing Chest Tenderness Nasalopharyngeal Ulceration Carotid Bruit
Pulmonary embolism
  • 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)
 ✔ ✔ ✔ (Low grade) ✔ ✔ (In case of massive PE) ✔ - - - -
Congestive heart failure
  • Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
    • SV1 or SV2 + RV5 or RV6 ≥3.5 mV
    • Total QRS amplitude in each of the limb leads ≤0.8 mV
    • R/S ratio <1 in lead V4
 ✔ ✔ ✔ - - ✔ - - - -
Percarditis
  • ST elevation
  • PR depression
  • Large collection of fluid inside the pericardial sac (pericardial effusion)
  • Calcification of pericardial sac
 ✔ ✔ ✔ (Low grade) ✔ (Relieved by sitting up and leaning forward) - ✔ - - - -
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks - 6 months)
    • Chronic (> 6 months)
Pneumonia ✔ ✔ ✔ ✔ - ✔ ✔ - - -
Vasculitis

Homogeneous, circumferential vessel wall swelling

✔ ✔ ✔ ✔ ✔ ✔ - ✔ ✔ ✔
Chronic obstructive pulmonary disease (COPD)
  • On CT scan:
  • On MRI:
    • Increased diameter of pulmonary arteries
    • Peripheral pulmonary vasculature attentuation
    • Loss of retrosternal airspace due to right ventricular enlargement
    • Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung
 ✔ ✔ - - - ✔ ✔ - - -


Other differentials

Pericarditis also resembles the following disorders and needs to be differentiated from them:


References

  1. ↑ American College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. "Pericardial disease." p. 64. ISBN 978-934465-28-8 [1]
  2. ↑ Brenes-Salazar JA (2014). "Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era". J Emerg Trauma Shock. 7 (1): 57–8. doi:10.4103/0974-2700.125645. PMC 3912657. PMID 24550636.
  3. ↑ "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".
  4. ↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
  5. ↑ "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".
  6. ↑ Ramani GV, Uber PA, Mehra MR (2010). "Chronic heart failure: contemporary diagnosis and management". Mayo Clin. Proc. 85 (2): 180–95. doi:10.4065/mcp.2009.0494. PMC 2813829. PMID 20118395.
  7. ↑ Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). "Symptom distress and quality of life in patients with advanced congestive heart failure". J Pain Symptom Manage. 35 (6): 594–603. doi:10.1016/j.jpainsymman.2007.06.007. PMC 2662445. PMID 18215495.
  8. ↑ Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). "Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology". Eur. J. Heart Fail. 11 (2): 130–9. doi:10.1093/eurjhf/hfn013. PMC 2639415. PMID 19168510.
  9. ↑ Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.
  10. ↑ Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.
  11. ↑ Nakawah MO, Hawkins C, Barbandi F (2013). "Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome". J Am Board Fam Med. 26 (4): 470–7. doi:10.3122/jabfm.2013.04.120256. PMID 23833163.
  12. ↑ Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). "Pericardial disease: diagnosis and management". Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
  13. ↑ Bogaert J, Francone M (2013). "Pericardial disease: value of CT and MR imaging". Radiology. 267 (2): 340–56. doi:10.1148/radiol.13121059. PMID 23610095.
  14. ↑ Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.
  15. ↑ Schmidt WA (2013). "Imaging in vasculitis". Best Pract Res Clin Rheumatol. 27 (1): 107–18. doi:10.1016/j.berh.2013.01.001. PMID 23507061.
  16. ↑ Suresh E (2006). "Diagnostic approach to patients with suspected vasculitis". Postgrad Med J. 82 (970): 483–8. doi:10.1136/pgmj.2005.042648. PMC 2585712. PMID 16891436.
  17. ↑ Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.
  18. ↑ Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). "Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease". COPD. 10 (1): 62–71. doi:10.3109/15412555.2012.727918. PMID 23413894.
  19. ↑ Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). "Electrocardiogram in pneumonia". Am. J. Cardiol. 110 (12): 1836–40. doi:10.1016/j.amjcard.2012.08.019. PMID 23000104.
  20. ↑ Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). "Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis". Int. J. Cardiol. 199: 170–9. doi:10.1016/j.ijcard.2015.06.087. PMID 26209947.
  21. ↑ Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). "Cardiac involvement in Churg-Strauss syndrome". Arthritis Rheum. 62 (2): 627–34. doi:10.1002/art.27263. PMID 20112390.

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