Uremic pericarditis differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Homa Najafi, M.D.[3],Amandeep Singh M.D.[4]

Overview

Pericarditis must be differentiated from other causes of chest pain such as myocardial infarction, aortic dissection, and pulmonary embolism.

Differentiating Pericarditis from other Diseases

Pericarditis can be misdiagnosed as myocardial infarction, aortic dissection, pneumonia, or pulmonary embolism and vice versa.

For a full discussion of the differential diagnosis of chest pain click here

For an expert algorithm that aids in the diagnosis of the cause of chest pain click here

Although the following features are not 100% sensitive and/or specific in distinguishing the different causes of chest pain, they are useful guides:

• 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.
• Unlike cardiac ischemia, the pain of pericarditis often lasts longer, and is unresponsive to vasodilator therapy.
• 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).
• 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:

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

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

Chest Pain Following Myocardial Infarction

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 pericardial fluid or pericardial biopsy, which requires high technical skill and is often not diagnostic (the yield from culture is low even with optimum specimens).

The Tygerberg scoring system is useful in ascertaining if pericarditis is due to tuberculosis. In order to calculate the score, the points are added together:

• Night sweats (1 point),
• Weight loss (1 point),
• Fever (2 point),
• Serum globulin > 40g/L (3 points),
• Blood total leukocyte count < 10 x 10⁹/L (3 points)

A total score of 6 or more is highly suggestive of tuberculous pericarditis. Pericardial fluid with an interferon-γ level greater than 50 pg/mL is highly specific for tuberculous pericarditis.

Other differentials

Pericarditis should be differentiated from other diseases presenting with chest pain, shortness of breath and tachypnea. The differentials include the following:

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
Percarditis	On contrast enhanced CT scan: Enhancement of the pericardium (due to inflammation) Pericardial effusion Pericardial calcification On gadolinium-enhanced fat-saturated T1-weighted MRI: Pericardial enhancement (due to inflammation) Pericardial effusion	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)	-	✔	-	-	-	-	Infections: Viral (Coxsackie virus, Herpes virus, Mumps virus, HIV) Bacteria (Mycobacterium tuberculosis-common in developing countries) Fungal (Histoplasmosis) Idiopathic in a large number of cases Autoimmune Uremia Malignancy Previous myocardial infarction	May be clinically classified into: Acute (< 6 weeks) Sub-acute (6 weeks - 6 months) Chronic (> 6 months)
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)	S1Q3T3 pattern representing acute right heart strain	Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign	✔	✔	✔ (Low grade)	✔	✔ (In case of massive PE)	✔	-	-	-	-	Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy)	May be associated with metabolic alkalosis and syncope
Congestive heart failure	On CT scan: Mediastinal lymphadenopathy Hazy mediastinal fat On MRI: Abnormality of cardiac chambers (hypertrophy, dilation) Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis) Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, amyloidosis, Anderson-Fabry's disease, Chagas disease)	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	Cardiomegaly	✔	✔	✔	-	-	✔	-	-	-	-	Previous myocardial infarction Hypertension (systemic and pulmonary) Cardiac arrythmias Viral infections (myocarditis) Congenital heart defects	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
Pneumonia	On CT scan: (not generally indicated) Consolidation (alveolar/lobar pneumonia) Peribronchial nodules (bronchopneumonia) Ground-glass opacity (GGO) Abscess Pleural effusion On MRI: Not indicated	Prolonged PR interval Transient T wave inversions	Consolidation (alveolar/lobar pneumonia) Peribronchial nodules (bronchopneumonia) Ground-glass opacity (GGO)	✔	✔	✔	✔	-	✔	✔	-	-	-	Ill-contact Travelling Smoking Diabetic Recent hospitalization Chronic obstructive pulmonary disease	Requires sputum stain and culture for diagnosis Empiric management usually started before culture results
Vasculitis	On CT scan: (Takayasu arteritis) Vessel wall thickening Luminal narrowing of pulmonary artery Masses or nodules (ANCA-associated granulomatous vasculitis) On MRI: Homogeneous, circumferential vessel wall swelling	Right or left bundle-branch block (Churg-Strauss syndrome) Atrial fibrillation (Churg-Strauss syndrome) Non-specific ST segment and T wave changes	Nodules Cavitation	✔	✔	✔	✔	✔	✔	-	✔	✔	✔	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
Chronic obstructive pulmonary disease (COPD)	On 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	Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies)	Enlarged lung shadows (emphysema) Flattening of diaphragm (emphysema)	✔	✔	-	-	-	✔	✔	-	-	-	Smoking Alpha-1 antitrypsin deficiency Increased sputum production (chronic bronchitis) Cough	Alpha 1 antitrypsin deficiency may be associated with hepatomegaly

References

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