Pericardial effusion differential diagnosis: Difference between revisions

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Revision as of 18:56, 5 August 2013

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

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 conditions that should be considered in differential diagnosis of pericardial effusion

Differential Diagnosis by Organ System

Cardiovascular	cathether ablation for arrhythmias, Coronary artery bypass grafting, dissecting aortic aneurysm, Dresslers syndrome, endocarditis, myocarditis, pacemaker insertion, percutaneous coronary intervention, postpericardiotomy syndrome, TAVI, thoracic surgery, valvuloplasty
Chemical / poisoning	Silicosis
Dermatologic	Behcet syndrome^[1]
Drug Side Effect	Dantrolene, doxorubicin, hydralazine, isoniazid, penicillin, phenylbutazone, procainamide
Ear Nose Throat	Temporal arteritis^[2]
Endocrine	Severe hypothyroidism (myxedema), Addisonian crisis
Environmental	No underlying causes
Gastroenterologic	Inflammatory bowel disease, Whipple's
Genetic	Gaucher disease, Jacobs arthropathy-camptodactyly syndrome, Mulibrey nanism syndrome, recurrent hereditary polyserositis
Hematologic	Leukemia, lymphoma
Iatrogenic	Cardiopulmonary resuscitation, postpericardiotomy syndrome, radiation therapy, serum sickness, thoracic duct obstruction secondary to tumor, surgery
Infectious Disease	Adenovirus, 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 pnuemonia, neisseria, nocardia, pneumococcus, proteus, pseudomonas, Rickettsia, salmonella, staphylococcus borrelia,brucellosis, streptococcus, toxoplasmosis, tuberculous, tularemia actinomycosis, varicella
Musculoskeletal / Ortho	No underlying causes
Neurologic	No underlying causes
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	Breast cancer, carcinoid, fibroma, kaposis sarcoma, leukemia, lipoma, lung cancer, lymphomas, mesothelioma, ovarian cancer, sarcoma melanoma, Sipple syndrome
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	Sarcoidosis
Renal / Electrolyte	Uremia
Rheum / Immune / Allergy	Systemic Lupus Erythematosus, rheumatoid arthritis, amyloidosis, ankylosing Spondylitis, Behcet syndrome, Kawasaki disease, mixed connective tissue disease, polyarteritis nodosa, polymyositis, Reiter's Syndrome, acute rheumatic fever, sarcoidosis, scleroderma, Still's disease, systemic sclerosis, temporal arteritis, Wegener's
Sexual	Neisseria gonorrhoeae^[3], treponema pallidum
Trauma	Blunt or penetrating chest trauma, esophageal rupture, esophogeal perforation, gastric perforation, pancreatic-pericardial fistula
Urologic	Renal Failure, Uremia
Miscellaneous	Idiopathic

References

↑ Scarlett JA, Kistner ML, Yang LC (1979). "Behçet's syndrome. Report of a case associated with pericardial effusion and cryoglobulinemia treated with indomethacin". Am J Med. 66 (1): 146–8. PMID 420242.
↑ Garewal HS, Uhlmann RF, Bennett RM (1981). "Pericardial effusion in association with giant cell arteritis". West J Med. 134 (1): 71–2. PMC 1272467. PMID 7210667.
↑ Wilson J, Zaman AG, Simmons AV (1990). "Gonococcal arthritis complicated by acute pericarditis and pericardial effusion". Br Heart J. 63 (2): 134–5. PMC 1024342. PMID 2317408.

Template:WikiDoc Sources

[pmid420242-1] Scarlett JA, Kistner ML, Yang LC (1979). "Behçet's syndrome. Report of a case associated with pericardial effusion and cryoglobulinemia treated with indomethacin". Am J Med. 66 (1): 146–8. PMID 420242.

[pmid7210667-2] Garewal HS, Uhlmann RF, Bennett RM (1981). "Pericardial effusion in association with giant cell arteritis". West J Med. 134 (1): 71–2. PMC 1272467. PMID 7210667.

[pmid2317408-3] Wilson J, Zaman AG, Simmons AV (1990). "Gonococcal arthritis complicated by acute pericarditis and pericardial effusion". Br Heart J. 63 (2): 134–5. PMC 1024342. PMID 2317408.

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[2]

[3]

@@ Line 1: / Line 1: @@
+__NOTOC__
 {{Pericardial effusion}}
 {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; [[Varun Kumar]], M.B.B.S.
-==Complete Differential Diagnosis of Pericardial Effusion by Organ System==
+==Overview==
-{|style="width:80%; height:100px" border="1"
+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 conditions that should be considered in differential diagnosis of pericardial effusion
+===Differential Diagnosis by Organ System===
+ {|style="width:80%; height:100px" border="1"
 |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
-|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" |Post-MI pericarditis in the immediate days following [[acute MI]] and [[Dresslers syndrome]] which develops later; [[dissecting aortic aneurysm]]; [[endocarditis]] and underlying [[myocarditis]].
+|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]]
-Following cardiovascular procedures such as: cathether ablation for [[arrhythmias]], coronary artery bypass grafting (CABG) ([[postpericardiotomy syndrome]]), [[pacemaker]] insertion, [[percutaneous coronary intervention]] with either dissection or perforation of the coronary artery,  [[TAVI]], thoracic surgery (resulting in [[chylopericardium]]), [[valvuloplasty]].
 |-
 |-bgcolor="LightSteelBlue"
@@ Line 19: / Line 26: @@
 |-bgcolor="LightSteelBlue"
 | '''Drug Side Effect'''
-|bgcolor="Beige"|Usually associated with small effusions.  Common culprits include [[hydralazine]], [[procainamide]], DOH, [[isoniazid]], [[phenylbutazone]], [[dantrolene]], [[doxorubicin]], methylsergide, [[penicillin]].
+|bgcolor="Beige"| [[Dantrolene]], [[doxorubicin]], [[hydralazine]], [[isoniazid]], [[penicillin]], [[phenylbutazone]], [[procainamide]]
 |-
 |-bgcolor="LightSteelBlue"
@@ Line 27: / Line 34: @@
 |-bgcolor="LightSteelBlue"
 | '''Endocrine'''
-|bgcolor="Beige"|Usually in conjunction with clinically severe [[hypothyroidism]].  Most early case reports associated with [[myxedema]] and patients also had [[ascites]], [[pleural effusion]]s and uveal edema. Often resolves with thyroid replacement therapy.  A pericardial effusion can be seen as part of an [[Addisonian crisis]].
+|bgcolor="Beige"| [[hypothyroidism|Severe hypothyroidism (myxedema)]], [[Addisonian crisis]]
 |-
 |-bgcolor="LightSteelBlue"
@@ Line 39: / Line 46: @@
 |-bgcolor="LightSteelBlue"
 | '''Genetic'''
-|bgcolor="Beige"| [[Gaucher disease]], [[Jacobs arthropathy-camptodactyly syndrome]], [[Mulibrey nanism syndrome]], [[Recurrent hereditary polyserositis]]
+|bgcolor="Beige"| [[Gaucher disease]], [[Jacobsen syndrome|Jacobs arthropathy-camptodactyly syndrome]], [[Mulibrey nanism|Mulibrey nanism syndrome]], [[recurrent hereditary polyserositis]]
 |-
 |-bgcolor="LightSteelBlue"
 | '''Hematologic'''
-|bgcolor="Beige"| [[Leukemia]], [[Lymphoma]]
+|bgcolor="Beige"| [[Leukemia]], [[lymphoma]]
 |-
 |-bgcolor="LightSteelBlue"
 | '''Iatrogenic'''
-|bgcolor="Beige"| [[Chylopericardium]] (from [[thoracic duct]] obstruction secondary to tumor, surgical procedure), [[Cardiopulmonary resuscitation]], [[Postpericardiotomy syndrome]], [[Radiation therapy]], [[Serum sickness]]
+|bgcolor="Beige"| [[Cardiopulmonary resuscitation]], [[postpericardiotomy syndrome]], [[radiation therapy]], [[serum sickness]], [[thoracic duct|thoracic duct obstruction secondary to tumor, surgery]]
 |-
 |-bgcolor="LightSteelBlue"
 | '''Infectious Disease'''
-|bgcolor="Beige"|
+|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]]
-'''Bacterial:''' [[Pneumococcus]], [[Streptococcus]] and [[Staphylococcus]] are most common.  Also [[Borrelia]],[[Brucellosis]], [[E.coli]], [[Francisella]], [[Haemophilus influenza]], [[Klebsiella]], [[Legionella]](preodominantly by hematogenous spread and approximately 20% by contiguous spread.  Usually these patients are quite ill), [[Meningococci]], [[Neisseria]], [[Proteus]], [[Psuedomonas]], [[Salmonella]], [[Tularemia]].
-'''Fungal:''' [[Actinomycosis]], [[Amebiasis]], [[Aspergillus]], [[Blastomycosis]], [[Candida]], [[Coccidiomycosis]],[[Echinococcus]], [[Histoplasmosis]], [[Nocardia]], [[Toxoplasmosis]].
-'''Helminthic:''' [[Alveolar hydatid disease]]
-'''Protozoal:''' [[Entamoeba histolytica]]
-'''Tuberculous:''' usually bloody, protein greater than 2.5. Initially mostly [[polymorphonuclear cells]], later [[lymphocytes]], [[monocytes]] and [[plasma cells]].  Usually develops very slowly with significant fibrous reaction.  Initially effusive then becomes constrictive. Other[[Mycoplasma]] such as [[mycoplasma pnuemonia]] can cause pericarditis is well.
-'''Viral:''' [[Coxsackie B Virus]], [[Echovirus]], [[Adenovirus]] (less commonly: [[CMV]]-especially in [[HIV]] patients, [[EBV]], [[Hepatitis B]], [[Influenza]], [[Mumps]], [[Varicella]]).
-'''Other:''' ,  [[Lyme disease]] (usually myopericarditis associated with conduction abnormalities). [[Rickettsia]]
 |-
 |-bgcolor="LightSteelBlue"
@@ Line 85: / Line 78: @@
 |-bgcolor="LightSteelBlue"
 | '''Oncologic'''
-|bgcolor="Beige"|Predominantly [[lung cancer]], [[breast cancer]], [[leukemia]], [[lymphomas]] ([[Hodgkins]] and non-Hodgkins).  Less commonly GI malignancies, [[ovarian cancer]], [[sarcoma]]s and [[melanoma]]s, metastic, hematogenous, [[carcinoma]], [[carcinoid]], [[Sipple syndrome]], [[mesothelioma]], [[fibroma]], [[lipoma]] .  Also [[Kaposis sarcoma]] in [[HIV]] positive patients.
+|bgcolor="Beige"|[[Breast cancer]], [[carcinoid]], [[fibroma]], [[kaposis sarcoma]], [[leukemia]], [[lipoma]], [[lung cancer]], [[lymphomas]], [[mesothelioma]], [[ovarian cancer]], [[sarcoma]][[melanoma]], [[Sipple syndrome]]
 |-
 |-bgcolor="LightSteelBlue"
@@ Line 105: / Line 98: @@
 |-bgcolor="LightSteelBlue"
 | '''Renal / Electrolyte'''
-|bgcolor="Beige"| In patients with [[renal failure]] most commonly there is a small pericardial effusion associated with pain and a [[pericardial friction rub]], but there can be a large effusion and present with [[tamponade]]
+|bgcolor="Beige"| [[Uremia]]
 |-
 |-bgcolor="LightSteelBlue"
 | '''Rheum / Immune / Allergy'''
-|bgcolor="Beige"|[[Systemic Lupus Erythematosus]] or [[SLE]]<ref name="pmid16154807">{{cite journal| author=Topaloglu S, Aras D, Ergun K, Altay H, Alyan O, Akgul A| title=Systemic lupus erythematosus: an unusual cause of cardiac tamponade in a young man. | journal=Eur J Echocardiogr | year= 2006 | volume= 7 | issue= 6 | pages= 460-2 | pmid=16154807 | doi=10.1016/j.euje.2005.07.010 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16154807  }} </ref>: Pericardial effusion usually occurs in the setting of disease flares (systemic symptoms, high erythrocyte sedimentation rate ([[ESR]]) , +ANA, +dsDNA, [[pleural effusion]]s).  Occurs in 20-40% of patients with [[SLE]] during the course of the disease.  Usually the fluid is serous or grossly bloody.  Analysis of the fluid usually reveals a high protein and low glucose content.  Typically [[WBC]] count is less than 10K, and is made up of primarily [[polymorphonuclear cell]]s ([[PMN]]s).
+|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]]
-[[Rheumatoid arthritis]] or [[RA]]: Pericardial effusion can occur without active joint involvement.  Also serous or bloody.  Usually the protein is > 5 mg/dl, and the glucose is low (<45).  The [[WBC]] is high at 20-90K.  Complement is usually low, and the latex fixation test is usually positive.
-Other: [[Amyloidosis]], [[Ankylosing Spondylitis]], [[Behcet syndrome]], [[Familial Mediterranian Fever]], [[Kawasaki disease]], [[Mixed Connective Tissue Disease]], [[Polyarteritis nodosa]] [[PAN]], [[Polymyositis]],[[Reiter's Syndrome]], acute [[Rheumatic fever]], [[Sarcoidosis]], [[Scleroderma]], [[Still disease]], [[Systemic sclerosis]], [[Temporal arteritis]] and , [[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="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"|After blunt or penetrating chest trauma
+|bgcolor="Beige"| [[chest trauma|Blunt or penetrating chest trauma]], [[esophageal rupture]], [[esophageal rupture|esophogeal perforation]], [[perforation|gastric perforation]], [[fistula|pancreatic-pericardial fistula]]
-Following cardiovascular procedures such as: cathether ablation for [[arrhythmias]], pacemaker insertion, [[percutaneous coronary intervention]] with either dissection or perforation of the coronary artery,  [[TAVI]], thoracic surgery (resulting in [[chylopericardium]], [[valvuloplasty]].
-Following gastrointestinal catastrophes including [[esophageal rupture]], pancreatic-pericardial fistula, esophogeal perforation, gastric perforation.
 |-
 |-bgcolor="LightSteelBlue"
@@ Line 133: / Line 118: @@
 |-bgcolor="LightSteelBlue"
 | '''Miscellaneous'''
-|bgcolor="Beige"| Commonly the diagnosis is idiopathic.
+|bgcolor="Beige"| [[Idiopathic]]
 |-
 |}