Pericardial effusion differential diagnosis: Difference between revisions

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{{Pericardial effusion}}
{{Pericardial effusion}}


{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; [[Varun Kumar]], M.B.B.S.
{{CMG}}; '''Associate Editor-In-Chief:''' {{AIA}}


==Overview==
==Overview==
Most pericardial effusions are caused by inflammation of the pericardium, a condition called pericarditis.  As the pericardium becomes inflamed, extra fluid is produced, leading to a pericardial effusion. Viral infections are one of the main causes of pericarditis and pericardial effusions. Infections causing pericardial effusions include [[ cytomegalovirus]], [[coxsackie virus]], [[echovirus]], and [[HIV]].  However, other conditions like injury to the pericardium or heart from a medical procedure, [[myocardial infarction]], [[uremia]], [[autoimmune disease]] and [[cancer]] should be considered in differential diagnosis of pericardial effusion.
Most pericardial effusions are caused by [[inflammation]] of the [[pericardium]], a condition called [[pericarditis]].  As the pericardium becomes inflamed, extra fluid is produced, leading to a [[pericardial effusion]]. [[Viral infections]] are one of the main causes of [[pericarditis]] and [[pericardial effusion]]<nowiki/>s. Infections causing pericardial effusions include [[ cytomegalovirus]], [[coxsackie virus]], [[echovirus]], and [[HIV]].  However, other conditions like injury to the pericardium or heart from a medical procedure, [[myocardial infarction]], [[uremia]], [[autoimmune disease]] and [[cancer]] should be considered in differential diagnosis of [[pericardial effusion]].


==Differentiating Pericardial Effusion from other Diseases==
==Differentiating Pericardial Effusion from other Diseases==


Chest pain or pressure are common symptoms. A small effusion may be asymptomatic. Larger effusions may cause [[cardiac tamponade]], a life-threatening complication and the signs of impending tamponade include [[dyspnea]], low [[blood pressure]], and distant [[heart sounds]].  There are several other cardiac insults with similar symptoms that should be considered in differential diagnosis of pericardial effusion.
[[Chest pain]] or pressure are common symptoms. A small effusion may be asymptomatic. Larger effusions may cause [[cardiac tamponade]], a life-threatening complication and the signs of impending tamponade include [[dyspnea]], low [[blood pressure]], and distant [[heart sounds]].  There are several other cardiac insults with similar symptoms that should be considered in differential diagnosis of pericardial effusion<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>:
 
{|
===Differential Diagnosis by Organ System===
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
{|style="width:80%; height:100px" border="1"
! rowspan="2" |<small>Diseases</small>
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
! colspan="3" |<small>Diagnostic tests</small>
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Catheter ablation|cathether ablation for arrhythmias]], [[CABG|coronary artery bypass grafting]], [[dissecting aortic aneurysm]], [[Dresslers syndrome]], [[endocarditis]], [[myocarditis]], [[pacemaker|pacemaker insertion]], [[percutaneous coronary intervention]], [[postpericardiotomy syndrome]], [[TAVI]], [[thoracic surgery]], [[valvuloplasty]]
! 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>
|-
|-
|-bgcolor="LightSteelBlue"
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Pulmonary_embolism Pulmonary embolism]
| '''Chemical / poisoning'''
| style="background: #F5F5F5; padding: 5px;" |
|bgcolor="Beige"| [[Silicosis]]
*On [https://www.wikidoc.org/index.php/CT_angiography CT angiography]:
**Intra-luminal filling defect
*On [https://www.wikidoc.org/index.php/MRI MRI]:
**Narrowing of involved [https://www.wikidoc.org/index.php/Blood_vessel vessel]
**No contrast seen distal to [https://www.wikidoc.org/index.php/Obstruction obstruction]
**Polo-mint sign (partial filling defect surrounded by contrast)
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Pulmonary_embolism_electrocardiogram S1Q3T3] pattern representing acute [https://www.wikidoc.org/index.php/Right_heart right heart] strain
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Fleischner_sign Fleischner sign] (enlarged pulmonary artery), [https://www.wikidoc.org/index.php/Hampton's_hump Hampton hump], [https://www.wikidoc.org/index.php/Westermark's_sign 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 ([https://www.wikidoc.org/index.php/Factor_V_Leiden Factor V Leiden], [https://www.wikidoc.org/index.php/Thrombophilia thrombophilia], [https://www.wikidoc.org/index.php/Deep_vein_thrombosis deep vein thrombosis], immobilization, [https://www.wikidoc.org/index.php/Malignancy malignancy], [https://www.wikidoc.org/index.php/Pregnancy pregnancy])
| style="background: #F5F5F5; padding: 5px;" |
*May be associated with [https://www.wikidoc.org/index.php/Metabolic_alkalosis metabolic alkalosis] and [https://www.wikidoc.org/index.php/Syncope syncope]
|-
|-
|-bgcolor="LightSteelBlue"
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Congestive_heart_failure Congestive heart failure]
| '''Dermatologic'''
| style="background: #F5F5F5; padding: 5px;" |
|bgcolor="Beige"|[[Behcet syndrome]]<ref name="pmid420242">{{cite journal| author=Scarlett JA, Kistner ML, Yang LC| title=Behçet's syndrome. Report of a case associated with pericardial effusion and cryoglobulinemia treated with indomethacin. | journal=Am J Med | year= 1979 | volume= 66 | issue= 1 | pages= 146-8 | pmid=420242 | doi= | pmc= | url= }} </ref>
*On [https://www.wikidoc.org/index.php/Computed_tomography CT scan]:
**[https://www.wikidoc.org/index.php/Mediastinal_lymphadenopathy Mediastinal lymphadenopathy]
**Hazy [https://www.wikidoc.org/index.php/Mediastinal mediastinal] fat
*On [https://www.wikidoc.org/index.php/Magnetic_resonance_imaging MRI]:
**Abnormality of [https://www.wikidoc.org/index.php/Cardiac cardiac] chambers ([https://www.wikidoc.org/index.php/Hypertrophy_(medical) hypertrophy], dilation)
**Delayed enhancement [https://www.wikidoc.org/index.php/MRI MRI] may help characterize the [https://www.wikidoc.org/index.php/Myocardial myocardial] [https://www.wikidoc.org/index.php/Tissue_(biology) tissue] ([https://www.wikidoc.org/index.php/Fibrosis fibrosis])
**Late enhancement of contrast in conditions such as [https://www.wikidoc.org/index.php/Myocarditis myocarditis], [https://www.wikidoc.org/index.php/Sarcoidosis sarcoidosis], [https://www.wikidoc.org/index.php/Amyloidosis amyloidosis], [https://www.wikidoc.org/index.php/Anderson-Fabry_disease Anderson-Fabry]'s disease, [https://www.wikidoc.org/index.php/Chagas_disease Chagas disease])
| style="background: #F5F5F5; padding: 5px;" |
*Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
**[https://www.wikidoc.org/index.php/S_wave S]V1 or [https://www.wikidoc.org/index.php/S_wave S]V2 + [https://www.wikidoc.org/index.php/R_wave R]V5 or [https://www.wikidoc.org/index.php/R_wave R]V6 ≥3.5 mV
**Total [https://www.wikidoc.org/index.php/QRS_complex QRS] amplitude in each of the limb leads ≤0.8 mV
**[https://www.wikidoc.org/index.php/R_wave R]/[https://www.wikidoc.org/index.php/S_wave S] ratio <1 in lead V4
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Cardiomegaly 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 [https://www.wikidoc.org/index.php/Myocardial_infarction myocardial infarction]
*[https://www.wikidoc.org/index.php/Hypertension Hypertension] ([https://www.wikidoc.org/index.php/Systemic_hypertension systemic] and [https://www.wikidoc.org/index.php/Pulmonary_hypertension pulmonary])
*[https://www.wikidoc.org/index.php/Cardiac_arrhythmia Cardiac arrythmias]
*[https://www.wikidoc.org/index.php/Viral Viral] infections ([https://www.wikidoc.org/index.php/Myocarditis myocarditis])
*[https://www.wikidoc.org/index.php/Congenital_heart_disease Congenital heart defects]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Right_heart_failure Right heart failure] associated with:
**[https://www.wikidoc.org/index.php/Hepatomegaly Hepatomegaly]
**Positive hepato-jugular reflex
**Increased [https://www.wikidoc.org/index.php/Jugular_venous_pressure jugular venous pressure]
**[https://www.wikidoc.org/index.php/Peripheral_edema Peripheral edema]
*[https://www.wikidoc.org/index.php/Left_heart_failure Left heart failure] associated with:
**[https://www.wikidoc.org/index.php/Pulmonary_edema Pulmonary edema]
**Eventual [https://www.wikidoc.org/index.php/Right_heart_failure right heart failure]
|-
|-
|-bgcolor="LightSteelBlue"
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Percarditis Percarditis]
| '''Drug Side Effect'''
| style="background: #F5F5F5; padding: 5px;" |
|bgcolor="Beige"| [[Dantrolene]], [[doxorubicin]], [[hydralazine]], [[isoniazid]], [[penicillin]], [[phenylbutazone]], [[procainamide]]
*On contrast enhanced [https://www.wikidoc.org/index.php/Computed_tomography CT scan]:
**Enhancement of the [https://www.wikidoc.org/index.php/Pericardium pericardium] (due to [https://www.wikidoc.org/index.php/Inflammation inflammation])
**[https://www.wikidoc.org/index.php/Pericardial_effusion Pericardial effusion]
**[https://www.wikidoc.org/index.php/Pericardial_calcification Pericardial calcification]
*On [https://www.wikidoc.org/index.php/Gadolinium gadolinium]-enhanced fat-saturated [https://www.wikidoc.org/index.php/Magnetic_resonance_imaging T1-weighted MRI]:
**[https://www.wikidoc.org/index.php/Pericardial Pericardial] enhancement (due to [https://www.wikidoc.org/index.php/Inflammation inflammation])
**[https://www.wikidoc.org/index.php/Pericardial_effusion 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:
**[https://www.wikidoc.org/index.php/Viral Viral] (Coxsackie virus, [https://www.wikidoc.org/index.php/Herpes_simplex_virus Herpes virus], [https://www.wikidoc.org/index.php/Mumps_virus Mumps virus], [https://www.wikidoc.org/index.php/Human_Immunodeficiency_Virus_(HIV) HIV])
**[https://www.wikidoc.org/index.php/Bacteria Bacteria] ([https://www.wikidoc.org/index.php/Mycobacterium_tuberculosis Mycobacterium tuberculosis]-common in developing countries)
**[https://www.wikidoc.org/index.php/Fungal Fungal] ([https://www.wikidoc.org/index.php/Histoplasmosis Histoplasmosis])
*Idiopathic in a large number of cases
*[https://www.wikidoc.org/index.php/Autoimmune Autoimmune]
*[https://www.wikidoc.org/index.php/Uremia Uremia]
*[https://www.wikidoc.org/index.php/Malignancy Malignancy]
*Previous [https://www.wikidoc.org/index.php/Myocardial_infarction myocardial infarction]
| style="background: #F5F5F5; padding: 5px;" |
*May be clinically classified into:
**Acute (< 6 weeks)
**Sub-acute (6 weeks - 6 months)
**Chronic (> 6 months)
|-
|-
|-bgcolor="LightSteelBlue"
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Pneumonia Pneumonia]
| '''Ear Nose Throat'''
| style="background: #F5F5F5; padding: 5px;" |
|bgcolor="Beige"|[[Temporal arteritis]]<ref name="pmid7210667">{{cite journal| author=Garewal HS, Uhlmann RF, Bennett RM| title=Pericardial effusion in association with giant cell arteritis. | journal=West J Med | year= 1981 | volume= 134 | issue= 1 | pages= 71-2 | pmid=7210667 | doi= | pmc=PMC1272467 | url= }} </ref>
*On [https://www.wikidoc.org/index.php/Computed_tomography CT scan]: (not generally indicated)
|-  
**[https://www.wikidoc.org/index.php/Consolidation_(medicine) Consolidation] ([https://www.wikidoc.org/index.php/Alveolar alveolar]/lobar pneumonia)
|-bgcolor="LightSteelBlue"
**Peribronchial [https://www.wikidoc.org/index.php/Nodules nodules] ([https://www.wikidoc.org/index.php/Bronchopneumonia bronchopneumonia])
| '''Endocrine'''
**[https://www.wikidoc.org/index.php/Ground_glass_opacification_on_CT Ground-glass opacity] (GGO)
|bgcolor="Beige"| [[hypothyroidism|Severe hypothyroidism (myxedema)]], [[Addisonian crisis]]
**[https://www.wikidoc.org/index.php/Abscess Abscess]
|-
**[https://www.wikidoc.org/index.php/Pleural_effusion Pleural effusion]
|-bgcolor="LightSteelBlue"
**On [https://www.wikidoc.org/index.php/MRI MRI]:
| '''Environmental'''
*Not indicated
|bgcolor="Beige"| No underlying causes
| style="background: #F5F5F5; padding: 5px;" |
*Prolonged [https://www.wikidoc.org/index.php/PR_interval PR interval]
*Transient [https://www.wikidoc.org/index.php/T_wave T wave] inversions
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Consolidation_(medicine) Consolidation] ([https://www.wikidoc.org/index.php/Alveolar alveolar]/lobar [https://www.wikidoc.org/index.php/Pneumonia pneumonia])
*Peribronchial [https://www.wikidoc.org/index.php/Nodules 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
*[https://www.wikidoc.org/index.php/Smoking Smoking]
*[https://www.wikidoc.org/index.php/Diabetes_mellitus Diabetic]
*Recent hospitalization
*[https://www.wikidoc.org/index.php/Chronic_obstructive_pulmonary_disease Chronic obstructive pulmonary disease]
| style="background: #F5F5F5; padding: 5px;" |
*Requires [https://www.wikidoc.org/index.php/Sputum sputum stain] and culture for diagnosis
*[https://www.wikidoc.org/index.php/Empiric_therapy Empiric management] usually started before [https://www.wikidoc.org/index.php/Culture_collection culture] results
|-
|-
|-bgcolor="LightSteelBlue"
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Vasculitis Vasculitis]
| '''Gastroenterologic'''
| style="background: #F5F5F5; padding: 5px;" |
|bgcolor="Beige"|[[Inflammatory bowel disease]], [[Whipple's]]
*On [https://www.wikidoc.org/index.php/Computed_tomography CT scan]: ([https://www.wikidoc.org/index.php/Takayasu's_arteritis Takayasu arteritis])
|-
**[https://www.wikidoc.org/index.php/Blood_vessel Vessel] wall thickening
|-bgcolor="LightSteelBlue"
**Luminal narrowing of [https://www.wikidoc.org/index.php/Pulmonary_artery pulmonary artery]
| '''Genetic'''
**Masses or nodules ([https://www.wikidoc.org/index.php/Anti-neutrophil_cytoplasmic_antibody ANCA]-associated granulomatous vasculitis)
|bgcolor="Beige"| [[Gaucher disease]], [[Jacobsen syndrome|Jacobs arthropathy-camptodactyly syndrome]], [[Mulibrey nanism|Mulibrey nanism syndrome]], [[recurrent hereditary polyserositis]]
*On [https://www.wikidoc.org/index.php/Magnetic_resonance_imaging MRI]:
|-
 
|-bgcolor="LightSteelBlue"
Homogeneous, circumferential [https://www.wikidoc.org/index.php/Blood_vessel vessel] wall [https://www.wikidoc.org/index.php/Swelling swelling]
| '''Hematologic'''
| style="background: #F5F5F5; padding: 5px;" |
|bgcolor="Beige"| [[Leukemia]], [[lymphoma]]
*[https://www.wikidoc.org/index.php/Bundle_branch_block Right or left bundle-branch block] ([https://www.wikidoc.org/index.php/Churg-Strauss_syndrome Churg-Strauss syndrome])
|-
*[https://www.wikidoc.org/index.php/Atrial_fibrillation Atrial fibrillation] ([https://www.wikidoc.org/index.php/Churg-Strauss_syndrome Churg-Strauss syndrome])
|-bgcolor="LightSteelBlue"
*Non-specific [https://www.wikidoc.org/index.php/ST_interval ST segment] and [https://www.wikidoc.org/index.php/T_wave T wave] changes
| '''Iatrogenic'''
| style="background: #F5F5F5; padding: 5px;" |
|bgcolor="Beige"| [[Cardiopulmonary resuscitation]], [[postpericardiotomy syndrome]], [[radiation therapy]], [[serum sickness]], [[thoracic duct|thoracic duct obstruction secondary to tumor, surgery]]
*[https://www.wikidoc.org/index.php/Nodule_(medicine) Nodules]
|-
*[https://www.wikidoc.org/index.php/Cavitation Cavitation]
|-bgcolor="LightSteelBlue"
| style="background: #F5F5F5; padding: 5px;" |✔
| '''Infectious Disease'''
| style="background: #F5F5F5; padding: 5px;" |✔
|bgcolor="Beige"|[[Adenovirus]], [[hydatid cyst|alveolar hydatid disease]], [[amebiasis]], [[aspergillus]], [[blastomycosis]], [[candida]], [[CMV]], [[coccidiomycosis]],[[echinococcus]], [[coxsackie B Virus]], [[escherichia coli]], [[EBV]], [[echovirus]], [[entamoeba histolytica]], [[francisella]], [[haemophilus influenza]], [[hepatitis B]], [[histoplasmosis]], [[influenza]], [[klebsiella]], [[legionella]], [[Lyme disease]], [[meningococci]], [[mumps]], [[mycoplasma|mycoplasma pnuemonia]], [[neisseria]], [[nocardia]], [[pneumococcus]], [[proteus]], [[pseudomonas]], [[Rickettsia]], [[salmonella]], [[staphylococcus]] [[borrelia]],[[brucellosis]], [[streptococcus]], [[toxoplasmosis]], [[tuberculous]], [[tularemia]][[actinomycosis]], [[varicella]]
| style="background: #F5F5F5; padding: 5px;" |✔
|-
| style="background: #F5F5F5; padding: 5px;" |✔
|-bgcolor="LightSteelBlue"
| style="background: #F5F5F5; padding: 5px;" |✔
| '''Musculoskeletal / Ortho'''
| style="background: #F5F5F5; padding: 5px;" |✔
|bgcolor="Beige"| No underlying causes
| style="background: #F5F5F5; padding: 5px;" | -
|-
| style="background: #F5F5F5; padding: 5px;" |✔
|-bgcolor="LightSteelBlue"
| style="background: #F5F5F5; padding: 5px;" |✔
| '''Neurologic'''
| style="background: #F5F5F5; padding: 5px;" |✔
|bgcolor="Beige"| No underlying causes
| style="background: #F5F5F5; padding: 5px;" |
|-
*[https://www.wikidoc.org/index.php/Takayasu's_arteritis Takayasu arteritis] usually found in persons aged 4-60 years with a mean of 30
|-bgcolor="LightSteelBlue"
*[https://www.wikidoc.org/index.php/Giant-cell_arteritis Giant-cell arteritis] usually occurrs in persons aged > 60 years
| '''Nutritional / Metabolic'''
*[https://www.wikidoc.org/index.php/Churg-Strauss_syndrome Churg-Strauss syndrome] may present with [https://www.wikidoc.org/index.php/Asthma asthma], [https://www.wikidoc.org/index.php/Sinusitis sinusitis], transient [https://www.wikidoc.org/index.php/Pulmonary pulmonary] infiltrates and neuropathy alongwith [https://www.wikidoc.org/index.php/Cardiac cardiac] involvement
|bgcolor="Beige"| No underlying causes
*Granulomatous vasculitides may present with [https://www.wikidoc.org/index.php/Nephritis nephritis] and [https://www.wikidoc.org/index.php/Upper_airway upper airway] ([https://www.wikidoc.org/index.php/Nasopharyngeal nasopharyngeal]) destruction
|-
| style="background: #F5F5F5; padding: 5px;" |
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"|[[Breast cancer]], [[carcinoid]], [[fibroma]], [[kaposis sarcoma]], [[leukemia]], [[lipoma]], [[lung cancer]], [[lymphomas]], [[mesothelioma]], [[ovarian cancer]], [[sarcoma]][[melanoma]], [[Sipple syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Opthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"|[[Sarcoidosis]]
|-
|-bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|bgcolor="Beige"| [[Uremia]]
|-
|-bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"|[[Systemic Lupus Erythematosus]], [[rheumatoid arthritis]], [[amyloidosis]], [[ankylosing Spondylitis]], [[Behcet syndrome]], [[Kawasaki disease]], [[mixed connective tissue disease]], [[polyarteritis nodosa]], [[polymyositis]], [[Reiter's Syndrome]], [[rheumatic fever|acute rheumatic fever]], [[sarcoidosis]], [[scleroderma]], [[Still's disease]], [[systemic sclerosis]], [[temporal arteritis]],  [[Wegener's]]
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| [[Neisseria gonorrhoeae]]<ref name="pmid2317408">{{cite journal| author=Wilson J, Zaman AG, Simmons AV| title=Gonococcal arthritis complicated by acute pericarditis and pericardial effusion. | journal=Br Heart J | year= 1990 | volume= 63 | issue= 2 | pages= 134-5 | pmid=2317408 | doi= | pmc=PMC1024342 | url= }} </ref>, [[treponema pallidum]]
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| [[chest trauma|Blunt or penetrating chest trauma]], [[esophageal rupture]], [[esophageal rupture|esophogeal perforation]], [[perforation|gastric perforation]], [[fistula|pancreatic-pericardial fistula]]
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| [[Renal Failure]], [[Uremia]]
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| [[Idiopathic]]
|-
|-
|}
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[https://www.wikidoc.org/index.php/Chronic_obstructive_pulmonary_disease Chronic obstructive pulmonary disease] (COPD)
| style="background: #F5F5F5; padding: 5px;" |
*On [https://www.wikidoc.org/index.php/Computed_tomography CT scan]:
**[https://www.wikidoc.org/index.php/Chronic_bronchitis Chronic bronchitis] may show [https://www.wikidoc.org/index.php/Bronchial bronchial] wall thickening, scarring with bronchovascular irregularity, [https://www.wikidoc.org/index.php/Fibrosis fibrosis]
**[https://www.wikidoc.org/index.php/Emphysema Emphysema] may show [https://www.wikidoc.org/index.php/Alveolar alveolar] septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe)
**Giant bubbles
*On [https://www.wikidoc.org/index.php/MRI MRI]:
**Increased diameter of [https://www.wikidoc.org/index.php/Pulmonary_arteries pulmonary arteries]
**Peripheral [https://www.wikidoc.org/index.php/Pulmonary pulmonary] [https://www.wikidoc.org/index.php/Vasculature 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;" |
*[https://www.wikidoc.org/index.php/Multifocal_atrial_tachycardia Multifocal atrial tachycardia] (atleast 3 distinct [https://www.wikidoc.org/index.php/P_waves P wave] morphologies)
| style="background: #F5F5F5; padding: 5px;" |
*Enlarged [https://www.wikidoc.org/index.php/Lung lung] shadows ([https://www.wikidoc.org/index.php/Emphysema emphysema])
*Flattening of [https://www.wikidoc.org/index.php/Diaphragm diaphragm] ([https://www.wikidoc.org/index.php/Emphysema 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;" |
*[https://www.wikidoc.org/index.php/Smoking Smoking]
*[https://www.wikidoc.org/index.php/Alpha_1-antitrypsin_deficiency Alpha-1 antitrypsin deficiency]
*Increased [https://www.wikidoc.org/index.php/Sputum sputum] production ([https://www.wikidoc.org/index.php/Chronic_bronchitis chronic bronchitis])
*[https://www.wikidoc.org/index.php/Cough Cough]
| style="background: #F5F5F5; padding: 5px;" |
*[https://www.wikidoc.org/index.php/Alpha_1-antitrypsin_deficiency Alpha 1 antitrypsin deficiency] may be associated with [https://www.wikidoc.org/index.php/Hepatomegaly hepatomegaly]
|}<br />


==References==
==References==

Latest revision as of 08:11, 2 March 2020

Pericardial effusion Microchapters

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Overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Abdelrahman Ibrahim Abushouk, MD[2]

Overview

Most pericardial effusions are caused by inflammation of the pericardium, a condition called pericarditis. As the pericardium becomes inflamed, extra fluid is produced, leading to a pericardial effusion. Viral infections are one of the main causes of pericarditis and pericardial effusions. Infections causing pericardial effusions include cytomegalovirus, coxsackie virus, echovirus, and HIV. However, other conditions like injury to the pericardium or heart from a medical procedure, myocardial infarction, uremia, autoimmune disease and cancer should be considered in differential diagnosis of pericardial effusion.

Differentiating Pericardial Effusion from other Diseases

Chest pain or pressure are common symptoms. A small effusion may be asymptomatic. Larger effusions may cause cardiac tamponade, a life-threatening complication and the signs of impending tamponade include dyspnea, low blood pressure, and distant heart sounds. There are several other cardiac insults with similar symptoms that should be considered in differential diagnosis of pericardial effusion[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]:

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
 ✔ ✔ - - - ✔ ✔ - - -


References

  1. ↑ 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.
  2. ↑ "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".
  3. ↑ 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.
  4. ↑ "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.
  9. ↑ Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ 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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