REcurrent Pericarditis

[Pamela]

My daughter who is 26 had surgery for co-archtation of the Aeorta 3 years ago.  Approximately 4 months after the surgery, she came down with Pericarditis. The attacks in the past varied starting at 6months, then 4, then 3, then everyother month, now they are once a month. It starts in her left ear, goes down her left shoulder and then into an attack of the pericarditis. She is currently under the care of a cardiologist who has said that the only option for her right now is Prednisone, since she has not had children. Right now, we are very discouraged because of this recurrence once a month.  One of her doctors at one time said that she might be allergic to the titanium clips used for the repair of her aorta.  Is this possible?  Can she be tested for an allergy such as this? Her cardiologist has said that this recurrent pericarditis is very rare and they just don't have an answer. She has been tested for autoimmune diseases and they came up negative.  Other than the Pericarditis, she is healthy. Have we covered all of our bases?  Thank You, Pam

[Cleveland Clinic, MD]

Dear Pam,

Thank you for your question.  I'm sorry to hear of your daughter's condition.  It sounds like she has chronic pericarditis.  There are two types of pericarditis, acute and chronic.  Acute pericarditis classically presents with progressive, often severe, chest pain over hours. This mechanical pain is typically postural, being worse on lying supine and relieved by sitting forward. It is often pleuritic and aggravated by coughing and swallowing. The pain may radiate to the neck, and less frequently to the arms and back, making differentiation from coronary ischemic pain more difficult. There is often a low-grade fever associated with viral and idiopathic pericarditis, while purulent pericarditis is associated with very high fevers and systemic sepsis.

The presence of a pericardial rub is pathognomonic for pericarditis, though its absence does not exclude the syndrome. This "to and fro" rasping sound has a timing consistent with the cardiac cycle. It is best appreciated with the diaphragm of the stethoscope applied to the lower left sternal edge and is creaking in nature-like leather on leather. The sound classically has a triple cadence, with components related to (a) atrial systole, (b) ventricular systole and (c) ventricular diastole. In one-third of cases, the rub is biphasic, while in 10% it is monophasic. The intensity of the sound can be attenuated by subcutaneous tissue thickness and hyperinflated lung volume. Further, the development of a pericardial effusion as part of the inflammatory syndrome can lead to waxing and waning of the rub over days, though a loud pericardial rub can still be heard occasionally in the presence of a significant effusion. The sound should be differentiated from a pleural rub, which, while similar in character, is timed with the respiratory cycle; subcutaneous emphysema, which may be an associate in post surgical or traumatic cases; and loud intracardiac murmurs such as ventricular septal defect.

Investigations
The electrocardiogram represents the most useful diagnostic test in acute pericarditis . Inflammation of the sub-epicardial myocardium is thought to be the mechanism producing ST- and T-wave changes, while inflammation of the atrium is thought to cause the PR-segment changes. In contrast to the regional ST changes of myocardial ischemia, pericarditis produces widespread ECG changes in limb and precordial leads. Four phases of ECG abnormalities have been recognized: Stage 1, with ST elevation and upright T waves, is present in 90% of cases. Over days the ST changes resolve and the ECG may look normal (Stage II). There may be further evolution to T-wave inversion (Stage III) and finally to normal (Stage IV).
The ECG abnormalities should be differentiated most importantly from acute myocardial ischemia. The ST changes are more widespread in pericarditis, lack Q-waves and have a typical "saddle-shaped" or concave appearance. The other important differential diagnosis of these ECG changes is the "early repolarization" pattern. While difficult without clinical correlation, differentiation can be made by the presence of PR segment elevation (especially aVR) and ST elevation in V6, which is uncommon in the early repolarization syndrome. Most patients with acute pericarditis remain in sinus rhythm.

Chest radiography contributes relatively little to the diagnosis of acute pericarditis. The presence of cardiomegaly may be seen in the minority of cases where a significant pericardial effusion has accumulated. Laboratory analysis of blood often shows a modest leukocytosis and raised sedimentation rate. Radionuclide scanning with In-111385, Ga-67386,387 has been reported to be useful in identifying the pericardium as the source of an inflammatory syndrome of unknown diagnosis in some patients. MRI, with Gd-DTPA enhancement, has identified specific regions of the pericardium involved in the inflammatory process.

The following diagnostic algorithm has been proposed. All patients should have a complete history and physical examination, electrocardiography, and chest radiography. Diagnosis specific testing should include tuberculin skin testing, rheumatoid factor and antinuclear antibody, viral studies from pharyngeal, and fecal swabs. In more complex cases (i.e., symptoms and signs lasting longer than 1 week, clinical evidence of tamponade, or purulent pericarditis), echocardiography, sputum/gastric aspirate for tubercle bacillus examination, and blood cultures are indicated. Pericardiocentesis (either percutaneous or surgical) is indicated for clinical tamponade, evidence for purulent pericarditis, high suspicion of tumor, or illness lasting longer than 1 week. Once these have been ruled out the diagnosis of chronic pericarditis is made.  This is usually treated with antiinflamatory medications and sometimes surgery is needed.

I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.

If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

[Pam]

Thank you very much for your reply to my question re:recurrent pericarditis of my daughter. You have given us some testing procedures, but I need to know if the cardiologist can perform all of the above procedures or do we need to come to the Cleveland clinic?  We have Johns Hopkins nearby and an excellent cardiac care facility, Fairfax Hospital, in Fairfax, Virginia.  Could you please explain the antinucular antibody test in laymans language. What would the pharyngeal and fecal swabs provide in testing?  Thank you again for your very prompt reply.  Pam

[Cleveland Clinic, MD]

Most cardiologists can order these tests but remember not all these tests need to be ordered.  The work-up is guided by what is the most probably cause.  Antinuclear antibody testing is a blood test that screens for autoimmune factors. The swabs are useful if a viral etiology is suspected.

[Sharon]

I read your post and I too had severe pericarditis.  Mine followed triple by-pass.  The doctors had me on steroids and each time I would taper and get off of the steroids the pericarditis would come back within 3 days I would be in that excuciating pain.  Then I would have to go back on steroids. The heart surgeon scheduled me for surgery 3 months after my first surgery and said he was going to remove the Pericardium sac around my heart.  But I canceled that surgery right before I was to have it and sought help elsewhere.  I went to an MD who treated me with homeopathic means.  He got me off of steroids and I have had no re-occurence of pericarditis.  This was 5 years ago. Not all homeopathic doctors treat the same.  If I could help you I would be happy to tell you how he treated me.  My email address is ***@****

[Tammy]

I just found this site and feel so much better already to know that I am not alone! I just turned 27 and have had Pericarditis for  a year and a half. It came out of nowhere. I was off work for 9 months while I tried to taper off the Prednisone. Every time I would get to 10 or 20 mg, it would come back with a VENGEANCE! While in High school, I suffered many bouts of Pleurisy and thought that's what it was. My Doctor thought so too, at first. I went to the UrgentCare every day for almost two weeks, before anything showed up on an EKG....an hour after that I saw a Cardiologist and had an Echo.....the next thing I knew I was admitted to the Cardiac Care Unit and the nearest hospital, where I stayed for the next four days. I barely remember it, but I will never forget the pain. It won't go away! At least once a month,I will get down to about 20mg and it comes back. All of my tests are negative for Lupus, but I see a Rhuematologist anyway. He says that 3% of people with Lupus will test negative for it, so I am treated like I have it. I am currently taking Prednisone, Plaquenil, cochicine, and various pain pills when needed. I also sometimes take Temezapam to help me sleep, since the Prednisone causes Insomnia and I have to make it to work as much as possible. Thankfully, I have great doctors, a great boss, wonderful parents and a very supportive Fiancee, who have been so good at putting up with me through all of this. I hope someday it will go away for good, but for now I deal with it on a day-to-day basis. As a matter of fact, this morning I woke up with the familiar pain shooting up into my left shoulder and pain upon breathing. I know how to work it now, so it doesnt get unbearable.....take lots of Prednisone!!! And rest as much as possible!!! :)
I would love to hear from others who suffer from this....it seems  sometimes like I am so alone. If you would like to correspond, or know of an online support group, please e-mail me at ***@****
Thanks so much!

[DALE PATRICK]

I Have had Paracarditis four or five times in the past ten years.  I would like to know the long and/or short term effects of this condition. I am to be scheduled for an Echocardiogram in the next week or two.  I have been told that this should show any scaring of the heart muscles.  How will this effect my later years, and can this possibly cause other heart problems, including heart attack?

[Carolyn]

I had pericarditis last fall with pleural effusion.  I spent 10 days in the hospital with drainage tubes (2) in pericardial sac and one in the left lung sac.  Since then I have been okay and have gotten off the predisone.  My attack was from a virus and I understand it could reoccur.  Does the virus stay in remissionin your body?  Should I expect the pericarditis and pleural effusion to reoccur?  I was told that I would have to make a life time change in my lifestyle by making sure I stay away from people I know are sick, hospitals, etc so that I do not become ill again - is this because of the immune system?  Thanks for answers if possible.

[kaiceelou]

A related discussion, Is it possible to have pericarditis for 5 years off and on? was started.

[mrwjd]

A related discussion, Recurrent pericarditis was started.