Chronic pericarditis in children

Chronic pericarditis in children. It is a clinical syndrome due to the inflammatory reaction of the pericardium in response to different attacks of a very diverse nature. Pericardial inflammation can result in the production of fluid in the pericardial sac, in which case there is talk of pericardial effusion, with the possible possibility of cardiac tamponade, or, less frequently, of retractable fibrous reaction of the pericardium leading to constrictive pericarditis. .

Summary

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  • 1 Origin
  • 2 Forms of presentation
  • 3 Etiology and clinical presentation
  • 4 Diagnosis
    • 1 Differential diagnosis
    • 2 Etiological diagnosis
  • 5 Treatment
  • 6 Complications
  • 7 Sources

Origin

Pericarditis can appear acutely or chronically, with both problems being quite different. Acute pericarditis should always be considered when evaluating a patient with chest pain. Retro-sternal discomfort that worsens with lying down, deep breathing, swallowing, or movement is characteristic of pericarditis. There may be severe retrosternal pain or pain that radiates to the neck or arms. Pain is generally relieved by adopting a forward leaning position or sitting. Fatigue is the form of presentation of chronic pericarditis secondary to progressive congestive heart failure caused by constriction.

Presentation forms

The form of presentation of pericarditis is highly variable: pure inflammation, inflammation with purulent effusion, sero Acute pericarditis is a clinical syndrome due to the inflammatory reaction of the pericardium in response to different attacks of a very diverse nature. Pericardial inflammation can result in the production of fluid in the pericardial sac, in which case we are talking about pericardial effusion, with the possible possibility of cardiac tamponade or, less frequently, retractile fibrous reaction of the pericardium that leads to slow sanguineous constrictive pericarditis. or hemorrhagic, with or without tamponade and fibrosis with or without constriction.

Viral pericarditis is the second most common cause of pericarditis in children. The enterovirus group, especially Coxsachie B, are usually responsible, although other viruses (adenovirus, cytomegalovirus, varicella-zoster virus, influenza, HIV) are involved. A history of upper respiratory infection 10 to 14 days before pericarditis is common. Clinically, the child appears affected in her general state, feverish and rarely presents with a significant pericardial effusion, however myocarditis (myopericarditis) is common.

Etiology and clinical presentation

The clinical picture includes fever, irritability or agitation, and chest or abdominal pain. On auscultation, it is frequent to find persistent pericardial rub or intermittent biphasic. Echocardiography is useful to detect small pericardial effusions; when the effusion is abundant, the heart sounds are muted and even the rub usually disappears. In purulent pericarditis the effusion settles quickly causing heart failure and compression compression of the heart, thus altering the adequate venous return during inspiration, producing “paradoxical” elevation of jugular venous pressure and a marked drop in systolic blood pressure and cardiac output (paradoxical pulse). Constrictive fibrosis is a sequel to purulent, viral, radiation, bartonellosis, or tuberculosis pericarditis.

Diagnosis

The radiological study shows “globular” enlargement of the cardiac silhouette when the pericarditis is accompanied by effusion. The pulmonary vasculature is normal. In constrictive pericarditis the cardiac shadow is small and the lung fields clear. The electrocardiogram (ECG) shows sinus tachycardia, low QRS complexes, and ST segment elevation.

Differential diagnosis

In the first hours of evolution, the picture of pericarditis can be confused with that of an acute myocardial infarction with elevation of the ST segment. However, there are usually elements that allow establishing the correct differential diagnosis in the vast majority of cases. A dissecting aortic aneurysm can rarely be confused with pericarditis if a correct anamnesis is made, since the pain is usually very abrupt, very intense and localized in the back rather than in the precordial region. It must be remembered, however, that the aortic aneurysm can rupture in the pericardial sac and cause cardiac tamponade. Pleuritic pain has common elements with pericarditis, but the pain is located laterally in the chest; However, The coexistence of pericarditis with pleuritis (pleuropericarditis) is quite frequent, so that the pain can have mixed characteristics. Pains originating in the chest wall also vary in intensity with movements, but painful sensitivity to local pressure allows the diagnosis to be established.

Etiological diagnosis

Once the syndromic diagnosis of pericarditis has been established, an attempt must be made to establish the etiological diagnosis. The first consideration to be made is to assess whether there is any underlying disease that may be the cause of pericarditis. Patients with kidney failure, recent myocardial infarction, cardiac surgery, radiation therapy to the chest, known malignancy, etc., may develop a picture of acute pericarditis that, logically, must be considered secondary to the underlying disease6. These etiologies are usually observed in patients admitted to hospital centers. The most frequent situation, however, especially in outpatients, is that pericarditis presents as a primary disease. In these cases, the vast majority (more than 90%) of pericarditis are idiopathic or viral.

Treatment

Treatment is determined by the type of pericarditis. The survival of patients with purulent pericarditis has improved with drainage by pericardiocentesis through echocardiographic guidance; the procedure prevents cardiac tamponade. Intrapericardial fibrinolytic therapy with streptokinase has been used in purulent pericarditis. Opening a pericardial window is useful for draining thick fluid and to prevent re-accumulation of the effusion, while pericardiectomy is indicated in constrictive pericarditis.

Antimicrobial administration is usually insufficient to treat purulent pericarditis, unless the infecting agent is Neisseria eningitidis , which only resolves with medical therapy; surgical drainage is essential. Initial treatment consists of intravenous administration of vancomycin or clindamycin together with cefotaxime or another.

Complications

  • Arrhythmias such as atrial fibrillation. When pericarditis accompanies myocarditis, other arrhythmias may occur, such as supraventricular tachycardia or complete cardiac obstruction.
  • Cardiac tamponade
  • Constrictive pericarditis: Inflammation of the pericardial sac causes fibrosis and thickening of the pericardium with adhesions (scarring that adhere) between the pericardium and the heart. The pericardium creates a rigid “box” around the heart and can severely limit the heart’s ability to fill with blood during diastole (relaxation phase before the next heartbeat). Patients with constrictive pericarditis can develop heart failure that responds poorly to treatment.
  • It is necessary to differentiate constrictive pericarditis from a chronic heart condition called restrictive cardiomyopathy, which produces symptoms and signs similar to constrictive pericarditis.

 

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