CHRONIC PERICARDITIS…
A Rheumatologist’s Perspective
Steven S. Overman, MD, MPH, FACR
The Seattle Arthritis Clinic
Clinical Professor of Medicine
University of Washington, Seattle, Washington USA
CHRONIC PERICARDITIS
A ‘Window’ to Chronic Arthritis
• The pericardial tissue that covers
the heart is similar to the synovial
tissue that lines the joints.
• The diagnostic and treatment
principles for pericarditis are the
same as those for chronic
arthritis.
• This means that a physician who
specializes in chronic arthritis may
be able to help your chronic
pericarditis patients.
My Background
• Private rheumatology practice for over 25 years
• Masters Degree in Public Health
• Robert Wood Johnson Clinical Scholar
• Board Certified: Rheumatology, Internal Medicine, &
Quality Assurance
• Medical Directorships
• Clinical Investigator
• American College of Rheumatology committees
and strategic planning
Clinical Professor of Medicine
University of Washington, Seattle
5 Principles of
Rheumatology Diagnosis &
Chronic Pericarditis
1) Search for infections
2) Understand how
rheumatology tests can
be useful (or misleading!)
3) Re-examine for rheumaticdisease signs
4) Search for organ problems
5) Treat and then re-evaluate
Sandra’s Pericarditis
• Sandra, age 49, developed
a sore throat and cough
after noticing an unusual
smell coming from her
home’s heating vents.
• Three weeks later, she
presented with syncope and
right-sided CHF.
Sandra’s Pericarditis
HOSPITAL
• Pericardial effusion and tamponade diagnosed
with echocardiography
• Pericardial window placed
• Cultures and tissue samples were culture (-)
• Troponins suggested myocardial damage
RHEUMATOLOGY TESTS
• ANA, RF were negative
• A family history of rheumatoid arthritis and
rheumatic fever was noted
Sandra’s Pericarditis
Outpatient
• Initially improved with colchicine and tapering
prednisone
8
•
•
•
weeks
Major flare with a 15x increase in C-reactive protein
Legionella IgM antibody found positive
Spondylitis was diagnosed based on X-ray diagnosis
of sacroiliitis and a (+) HLA-B27
12 months
• Recurrent flares of “reactive pericarditis” were
treated with typical anti-rheumatic drugs methotrexate, tapering prednisone, and biologic
therapies. Sandra has improved.
MILD Acute Pericarditis
• No hemodynamic
problems
• No fever
• Not immunosuppressed
• Responds to aspirin or
NSAIDs and colchicine
SEVERE Acute Pericarditis
• Fever >38 C
• Follows trauma or
myocardial infarcts
• Cardiac tamponade
• Does not respond to
first-line therapy
Pericarditis Differential Diagnosis
• Infections
tuberculosis, malaria, bacterial,
atypical bacterial, viral,
spirocheaeteal, fungal,
helminthes infections
• Inflammatory
• Neoplastic
• Myocarditis or post-myocardial
infarct
• Metabolic
• Traumatic
• Radiation
5 Principles of
Rheumatology Diagnosis &
Chronic Pericarditis
1)SEARCH FOR INFECTIONS
• Routine blood and pericardial fluid
examinations
• Adenosine deaminase <40 means no
TB 97% of the time
• Serologies check for infections
not easily cultured
Diagnosing Active Tuberculosis
NEWEST TEST
GeneXpert is the newest gene
array identification technology
that can identify the tuberculosis
bacillus from body fluid in 2 hours.
This test can simultaneously
identify TB and resistance to
rifampicin.
Sandra’s Infection
• Legionnaire’s disease
– Acute respiratory illness after
heating system smell. The
organism is found in heating,
cooling, and humidifying systems
in communities and hospitals.
– Pericardial fluid culture (-)
Myocarditis with pericarditis is
the most common extrapulmonary manifestation (30%).
– IgM Legionnella Ab positive
proved the diagnosis.
5 Principles of
Rheumatology Diagnosis &
Chronic Pericarditis
1) Search for infections
2) UNDERSTAND HOW
RHEUMATOLOGY
TESTS CAN BE
USEFUL
(OR MISLEADING!)
Common Inflammation Markers
• C-reactive protein and
sedimentation rate are
often - but not always increased in rheumatic
syndromes.
• Unfortunately, they are still
non-specific and are
increased in infections.
Auto-antibody Patterns in
Inflammatory Rheumatic Diseases
• SERO-POSITIVE means an auto-antibody is positive
– Rheumatoid Factor (RF)
– Anti-cyclic citrullinated peptide (anti-CCP)
– Antinuclear Antibody (ANA)
– Anti-double stranded DNA (anti-dsDNA)
– Extractable Nuclear Antibody (ENA), SSA, SSB, Scl-70,
RNP, Sm, and others
– Anti-neutrophil cytoplasmic antibody (pANCA/cANCA)
• SERO-NEGATIVE means ALL auto-antibodies are negative
Sandra’s Post-infectious,
Sero-negative
Inflammatory Reaction
• INITIAL: Legionella
myocarditis and pericarditis
• BUT, LATER: reactive
pericarditis “skyrocketed”
her CRP, although all autoantibodies were negative.
5 Principles of
Rheumatology Diagnosis &
Chronic Pericarditis
1) Search for infections
2) Understand how
rheumatology tests
can be useful (or misleading!)
3) Re-examine for
rheumatic-disease
signs
Sero-negative
SYSTEMIC LUPUS ERYTHEMATOSIS
•
•
•
•
•
•
•
•
•
•
Malar rash
Discoid rash
Photosensitivity
Oral ulcers
Arthritis
Pleuritis or pericarditis
Renal disorder
Seizures or psychosis
Hematologic disorder
Anti-dsDNA, anti-Sm, or
anti-phospholipid Ab
• Antinuclear antibodies
Sero-negative
MEDIUM VESSEL VASCULITIS
• Polyarteritis nodosa
• Behcet’s syndrome
• Churg-Strauss syndrome
Sero-negative
RHEUMATOID ARTHRITIS
• Rheumatoid nodules
• Pericarditis
• Premature cardiovascular mortality
• Vasculitis
• Lung disease
Sero-negative
RHEUMATIC FEVER
• Erythema marginatum
• Subcutaneous nodules
• Migratory arthritis
• Carditis and valvulitis
• Central nervous system
involvement
Sero-negative
ADULT STILL’S DISEASE
• Arthralgias or arthritis
• Nonpruritic, ‘salmon’ colored,
maculopapular rash
• Lymphadenopathy
• Hepatomegaly or splenomegaly
•
•
•
•
Leukocytosis
Sore throat
Abnormal liver function
Negative tests for antinuclear
antibody and rheumatoid
factor
Sero-negative
SPONDYLOARTHRITIS
SYNDROMES
Sandra’s Sacroliitis
Sero-negative
SPONDYLOARTHRITIS
SYNDROMES
• Ankylosing spondylitis
• Psoriatic spondyloarthritis
• Reactive spondyloarthritis
• Inflammatory bowel-associated spondyloarthritis
• Undifferentiated spondyloarthritis and enthesitis
Sero-negative
PSORIASIS ARTHRITIS
DIP Swelling, but not osteoarthritis
Sero-negative
PSORIASIS
nail-bed pitting
Sero-negative
PSORIASIS
Onycholysis
Sero-negative
REACTIVE ARTHRITIS
keratoderma blennorrhagicum
Sero-negative
REACTIVE ARTHRITIS
dactylitis and keratoderma
5 Principles of
Rheumatology Diagnosis &
Chronic Pericarditis
1) Search for infections
2) Understand how rheumatology
tests can be useful (or misleading!)
3) Re-examine for rheumatic-disease
signs
4) SEARCH FOR ORGAN
PROBLEMS
SEARCH FOR ORGAN PROBLEMS
Sandra’s evaluation
• Heart
• Lungs
• Gastrointestinal
• Endocrine
• Renal
• Liver
• Eyes and Brain
• Large vessels
• Joints
5 Principles of
Rheumatology Diagnosis &
Chronic Pericarditis
1) Search for infections
2) Understand how rheumatology
blood tests can be useful
(or misleading!)
3) Re-examine for rheumaticdisease signs
4) Search for organ problems
5) TREAT & RE-EVALUATE
Chronic Pericarditis Treatments
are the same as
Chronic Arthritis Treatments
• Antibiotics
• NSAIDs (ibuprofen; aspirin)
and colchicine
• Corticosteroids
• Disease-modifying drugs
• Biologic injects
Sandra’s Chronic Pericarditis
5 PRINCIPLES
SANDRA’s CARE
1) Search for infections
1) Pericardial fluid cultures were
negative, but her serology for
Legionella infection was positive.
2) Understand rheumatology
tests
2) General inflammation tests became
positive, but all auto-antibody tests
were negative.
3) Re-examine for rheumatic
disease signs
3) She had no new signs, but showed
sacroiliitis on X-ray.
4) Search for organ problems
4) Kidney and liver function
normalized when the tamponade
was relieved.
5) Treat and re-evaluate
5) With treatment for reactive
pericarditis and spondyloarthritis,
Sandra is improved, but not cured.
The Seattle Arthritis Clinic
The Pericarditis Charts on My Desk
When I Left Seattle…
Seattle Arthritis Clinic
18 Chronic Pericarditis Cases
• Ages: 16 to 83 years
• Gender: 11 women and 7 men
• Sero-positive Conditions: 5
Antibodies: Anti-DNA, ANA, RNP, SS-A, SS-B
Diagnoses: Systemic Lupus Erythematosis (1)
Sjogren’s Syndrome (1)
Undifferentiated Connective Tissue Disease (3)
• Sero-negative Conditions: 13
Antibodies: ALL NEGATIVE
Diagnoses: Reactive Spondyloarthropathy (1)
Psoriasis Spondyloarthropathy (2)
Undifferentiated Spondyloarthropathy (8)
No underlying disease identified (2)
Sandra’s
‘Take Home Message’
1)
Infections can trigger
reactive inflammatory
pericarditis and arthritis.
2)
Sero-negative syndromes
such as spondyloarthritis are
very common.
3)
The 5 Principles of
Rheumatology Diagnosis
will help you rule out
infections, and identify the
patterns of rheumatic disease.
THANK YOU
University of Washington and Northwest Medical Center