Pericardial effusion differential diagnosis
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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.
Causes of Pericardial Effusion Based Upon Composition of Effusion
Serous
- Acute pancreatitis
- Chemotherapeutics
- Chronic disease
- Cirrhosis
- Congestive heart failure
- Dressler's syndrome
- Hypoalbuminemia
- Hypothyroidism
- Infection
- Irradiation
- Malnutrition
- Nephrotic Syndrome
Blood
- Acute myocardial infarction
- Anticoagulants
- Aortic rupture
- Cardiac catheterization
- Chemotherapeutics
- Coagulotherapy
- Heart surgery
- Neoplasm
- Perforation
- Trauma
- Uremia
Lymph or Chylous
- Benign obstruction of thoracic duct
- Idiopathic
- Neoplasm
Metastatic Tumor
Miscellaneous
Infectious
Noninfectious
- Idiopathic
- Uremia: Kidney failure with excessive blood levels of urea nitrogen
- Heart surgery[1]
- Neoplasia that has spread to the pericardium
- Acute myocardial infarction: Post myocardial infarction pericarditis (Dressler's syndrome)
- Postirradiation
- Aortic dissection (with leakage into pericardial sac)
- Trauma
- Sarcoidosis
- Pericarditis
Hypersensitivity or Autoimmunity Related
Underlying Causes of Pericardial Effusion by Organ System
| Cardiovascular | Post-MI pericarditis in the immediate days following acute MI and Dresslers syndrome which develops later; dissecting aortic aneurysm; endocarditis and underlying myocarditis.
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. |
| Chemical / poisoning | Silicosis |
| Dermatologic | Behcet syndrome[2] |
| Drug Side Effect | Usually associated with small effusions. Common culprits include hydralazine, procainamide, DOH, isoniazid, phenylbutazone, dantrolene, doxorubicin, methylsergide, penicillin. |
| Ear Nose Throat | Temporal arteritis[3] |
| Endocrine | Usually in conjunction with clinically severe hypothyroidism. Most early case reports associated with myxedema and patients also had ascites, pleural effusions and uveal edema. Often resolves with thyroid replacement therapy. A pericardial effusion can be seen as part of an 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 | Chylopericardium (from thoracic duct obstruction secondary to tumor, surgical procedure), Cardiopulmonary resuscitation, Postpericardiotomy syndrome, Radiation therapy, Serum sickness |
| Infectious Disease |
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. OtherMycoplasma 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 |
| Musculoskeletal / Ortho | No underlying causes |
| Neurologic | No underlying causes |
| Nutritional / Metabolic | No underlying causes |
| Obstetric/Gynecologic | No underlying causes |
| Oncologic | Predominantly lung cancer, breast cancer, leukemia, lymphomas (Hodgkins and non-Hodgkins). Less commonly GI malignancies, ovarian cancer, sarcomas and melanomas, metastic, hematogenous, carcinoma, carcinoid, Sipple syndrome, mesothelioma, fibroma, lipoma . Also Kaposis sarcoma in HIV positive patients. |
| Opthalmologic | No underlying causes |
| Overdose / Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | Sarcoidosis |
| Renal / Electrolyte | 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 |
| Rheum / Immune / Allergy | Systemic Lupus Erythematosus or SLE[4]: Pericardial effusion usually occurs in the setting of disease flares (systemic symptoms, high erythrocyte sedimentation rate (ESR) , +ANA, +dsDNA, pleural effusions). 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 cells (PMNs).
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. |
| Sexual | Neisseria gonorrhoeae[5], Treponema pallidum |
| Trauma | After blunt or penetrating chest trauma
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. |
| Urologic | Renal Failure, Uremia |
| Miscellaneous | Commonly the diagnosis is idiopathic. |
References
- ↑ Pericardial effusion:What are the symptoms?, Dr. Martha Grogan M.D.
- ↑ 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.
- ↑ Topaloglu S, Aras D, Ergun K, Altay H, Alyan O, Akgul A (2006). "Systemic lupus erythematosus: an unusual cause of cardiac tamponade in a young man". Eur J Echocardiogr. 7 (6): 460–2. doi:10.1016/j.euje.2005.07.010. PMID 16154807.
- ↑ 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.