Pericarditis pathophysiology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S.; Cafer Zorkun, M.D., Ph.D. [2]

Overview

Pericarditis is inflammation of the pericardium, which is the double-walled sac that contains the heart and the roots of the great vessels. There can be an accompanying accumulation of fluid that can be either serous (free flowing fluid) or fibrinous (an exudate, which is a thick fluid composed of proteins, fibrin strands, inflammatory cells, cell breakdown products, and sometimes bacteria). Vascular congestion of the pericardium is also present. The underlying myocardium may or may not be inflamed as well. If the myocardium is involved in the inflammatory process, it is called myopericarditis, and CK and troponin levels may be elevated.

Pathogenesis

• Cardiotropic viruses usually spread to the myocardium and pericardium hematogenously and cause acute inflammation with infiltration of polymorphonuclear (PMN) leukocytes and pericardial vascularization. This may cause pericardial effusion and fibrinous change of the pericardium. The pericardium may also develop a serous or hemorrhagic effusion. Most patients with viral pericarditis recover completely with few developing recurrences. Some patients develop constrictive pericarditis which could be disabling.

• Bacterial pericarditis results from:

1. Contiguous spread of infection within the chest, either de novo or after surgery or trauma.
2. Spread from infective endocarditis
3. Hematogenous spread of infection
4. Direct inoculation as a result of penetrating injury or cardiothoracic surgery

• Tuberculous pericarditis develops from lymphatic spread of peritracheal, peribronchial or mediastinal lymph nodes or by contiguous spread from a focus of infection in the lung or pleura. There are four pathologic stages observed:

• Stage 1: Presence of diffuse fibrin deposition, granulomas and abundant mycobacterium.

• Stage 2: Development of serous or serosanguineous pericardial effusion with a predominantly lymphocytic exudate with monocytes and foam cells.

• Stage 3: Absorption of effusion with organization of granulomatous caseation and thickening of pericardium secondary to deposition of fibrin and collagen.

• Stage 4: Development of constrictive pericarditis. The pericardial space is obliterated by dense adhesions with marked thickening of parietal layer and replacement of granulomas by fibrous tissue.

These types of granulomatous pericarditis also occur with fungal infections, rheumatoid arthritis (RA), and sarcoidosis.

• Pericarditis in renal failure is thought to result from inflammation of the visceral and parietal layers of the pericardium by metabolic toxins such as urea, creatinine, uric acid, methylguanidine, guanidinoacetate, parathyroid hormone, beta2-microglobulin, and others. It may be associated with hemorrhagic or serous effusion.

Gross Pathology Images

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

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  Fibrinous pericarditis: Gross, natural color, an excellent example of bread and butter appearance. Uremia, chronic glomerulonephritis and sepsis.

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  Fibrinous pericarditis: Gross, a good example (bread and butter appearance).

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  Fibrinous pericarditis: Gross, an excellent example.

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  Fibrinous pericarditis: Gross, an excellent example, close-up view of fibrin.

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  Fibrinous pericarditis: Gross, an excellent example, close-up view.

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  Fibrinous pericarditis: Gross, an excellent example.

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  Fibrinous pericarditis: Gross, external view of localized pericarditis over an acute infarction.

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  Fibrinous pericarditis: Gross, intact heart, good example.

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  Fibrinous pericarditis: Gross, good example, mild, with small amount of fibrin.

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  Fibrinous pericarditis: Gross, close-up, an excellent example of color and detail.

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  Fibrinous pericarditis: Gross, a good example.

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  Fibrinous pericarditis: Gross, a good example, very mild case.

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  Fibrinous pericarditis: Gross, an excellent example.

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  Fibrinous pericarditis: Gross, a close-up view, an excellent illustration of fibrinous exudate.

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  Pericarditis in uremia.

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  Fibrinous pericarditis: Gross, fixed tissue (note to color changes), a close-up view of fibrin on epicardial surface of heart, a typical example.

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  Fibrinous pericarditis: Gross, natural color, large right atrial thrombus and fibrinous pericarditis. Normal tricuspid valve with some aging changes (good example).

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  Fibrinous pericarditis: Gross, natural color.

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  Fibrinous pericarditis: Gross, natural color, an excellent example.

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  Fibrinous pericarditis: Gross, natural color, very close-up photo showing fibrinous exudate simulating frost (an excellent example).

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  Rheumatoid fibrinous pericarditis: Gross, natural color, a typical lesion in 22 years old white female due to juvenile rheumatoid arthritis.

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  Fibrinous pericarditis: Gross, natural color, close-up view of minimal fibrinous exudate on epicardial surface due to terminal renal failure.

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  Fibrinous pericarditis: Gross, natural color, anterior view of heart with mild fibrinous exudate over epicardium due to terminal renal failure.

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  Tuberculous pericarditis: Gross, natural color, shaggy hemorrhagic exudate. This case is much more hemorrhagic than the typical tuberculous pericarditis.

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  Heart transplant: Gross, natural color, external view of heart. Two months after transplantation with fibrinous pericarditis.

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  Neoplastic pericarditis: Gross, natural color, shaggy pericarditis. Primer is adenocarcinoma of the lung.

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  Heart: Septic pericarditis.

Microscopic Pathology Images

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

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  Tuberculous pericarditis.

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  Tuberculous pericarditis.

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  Tuberculous pericarditis: Micro oil acid fast stain. The organism easily seen.

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  Tuberculous pericarditis: Micro oil acid fast stain. The organism easily seen.

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  Uremic pericarditis: Micro med mag, H&E. A good example

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  Tuberculous pericarditis: Micro med mag, H&E, a typical lesion

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  Fibrinous pericarditis.

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  Pericarditis fibrinosa (Fibrinous pericarditis).

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  Malignant Mesothelioma, Biphasic Type: Pericardium: This tumor has epithelioid cells (lower half) surrounded by spindled cells. The patient was a 46-year-old woman with constrictive pericarditis; the pericardium was studded with coalescing tumor nodules.

Videos

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Acute Fibrinous Pericarditis

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