11. Pericardial disease

Question 1

Definition of pericarditis

Answer 1

Inflammation of the pericardium due to infectious agents (primary pericarditis) or secondary causes; pericarditis takes on several different forms in both acute and chronic types

Question 2

Causes of pericarditis

Answer 2

1. Infectious agents
   - Most commonly viral or tuberculosis
2. Post-myocardial infarction (Dressler syndrome)
3. Post-operative pericarditis
4. Malignant metastases
5. Uremic pericarditis
6. Immune-mediated
   - SLE, rheumatic fever, scleroderma

Question 3

Types of acute pericarditis

Answer 3

1. Serous pericarditis
2. Fibrinous pericarditis
3. Suppurative pericarditis
4. Hemorrhagic pericarditis
5. Caseous pericarditis

Question 4

Serous pericarditis

Answer 4

1. Causes: non-infectious inflammatory diseases
   (immune-mediated, uremic, tumours)
2. Serous effusions with a mild inflammatory infiltrate in the epipericardial fat
3. Rarely organizes into fibrous adhesions

Question 5

Fibrinous pericarditis

Answer 5

1. Causes: post-myocardial infarction, rheumatic fever, post-surgery
2. Serous fluid mixed with a fibrinous exudates
3. Clinically, indicated by a loud pericardial friction rub

Question 6

Suppurative pericarditis

Answer 6

1. Causes: infections
2. Acute inflammation with cloudy exudate (or frank
   pus in severe cases)
3. Usual outcome is organization by scarring, hence
   frequently produces constrictive pericarditis

Question 7

Hemorrhagic pericarditis

Answer 7

1. Causes: malignant metastases, bacterial infections
2. Exudate composed of blood mixed with fibrinous or
   suppurative effusion

Question 8

Caseous pericarditis

Answer 8

1. Causes: tuberculosis (direct spread from tuberculous foci within tracheobronchial nodes)
2. Usually leads to constrictive pericarditis

Question 9

Types of chronic (healed) pericarditis

Answer 9

1. Adhesive pericarditis

2. Constrictive pericarditis

Question 10

Adhesive pericarditis

Answer 10

1. Causes: infections, post-cardiac surgery
2. Pericardial sac is obliterated, with adherence of parietal layer to surrounding thoracic structures
3. Heart hence needs to pull against attached structures during systole
4. Characteristic clinical findings: systolic retraction of rib cage & diaphragm, pulsus paradoxus, cardiac hypertrophy & dilation

Question 11

Constrictive pericarditis

Answer 11

1. Causes: prior suppurative or caseous pericarditis
2. Pericardial sac is obliterated, with heart enclosed in a dense fibrous or fibrocalcific scar which can resemble a plaster mold in severe cases (concretio cordis)
3. Diastolic expansion is hence limited (cardiac output reduced at rest, with little capacity to increase in response to increased peripheral needs)
4. No cardiac hypertrophy or dilation can occur due to dense enclosing scar