1Case Report Post Op Pericardial Effusion ec RHDPresenter: Ramos
(100100125)Dina Utami (10010010)!uper"isor : dr# $u%ammad &li'
!p#& (()INTRODUCTION&cuter%eumaticfe"er
(&R))isanauto*immuneconse+uenceofinfection,it%t%e-acterium
.roup & streptococcus (/&!)# 0t causes an acute .eneralised
in1ammator2response and an illness t%at aects onl2 certain parts of
t%e -od2 3 mainl2 t%e %eart'4oints' -rain and s5in# 0ndi"iduals
,it% &R) are often se"erel2 un,ell' in .reat
pain'andre+uire%ospitalisation# Despitet%edramaticnatureof
t%eacuteepisode' &R)lea"es no lastin. dama.e to t%e -rain'
4oints or s5in# &cute r%eumatic fe"er (&R)) is anillness
caused-2areactiontoa-acterial infection' ,%ic%oftenresults
inlastin.dama.e to %eart "al"es# 6%is is 5no,n as r%eumatic %eart
disease (RHD) and it is animportant cause of premature mortalit2#
&lmost all cases of RHD and associated deat%sare pre"enta-le#
Ho,e"er' &R) and RHDremain common in man2 de"elopin.countries#
RHD is t%e most fre+uent form of %eart disease in c%ildren
,orld,ide#1&cuter%eumaticfe"erisanon*suppurati"ecomplicationof.roup
& -eta%emol2ticstreptococcal (/&7H!) sore t%roat# 0t
affects 4oints' s5in' su-cutaneous tissue' -rainand %eart# E8cept
%eart' all ot%er effects are re"ersi-le' needin. onl2 s2mptomatic
reliefdurin.t%eepisodes# Cardiaccomplications aresi.nificant
ina-senceof secondar2prop%2la8is and culminate into c%ronic and
life t%reatenin. "al"ular %eart disease# 26%e onl2 cost*effecti"e
approac% to controllin. RHD is secondar2 prop%2la8is in t%eform of
penicillin in4ections e"er2 9:; ,ee5s to pre"ent recurrent attac5s
of .roup &streptococcal infection t%at cause &R) and' t%us'
t%e ,orsenin. of RHD#Ho,e"er' t%ema4orit2of patients ,%oenroll
intore.ister*-asedpro.rams ares2mptomatic,it%ad"anced disease'
indicatin. t%at t%e2 %a"e %ad a num-er of silent or undetected
attac5sof &R)# Patients ,it% mild' as2mptomatic RHD %a"e t%e
most to .ain from second* ar2prop%2la8is -ecause' int%ea-senceof
&R)recurrence' t%ema4orit2,ill %a"eno2detecta-le disease ,it%in
5:10 2ears# !creenin. to detect as2mptomatic cases is't%erefore' an
attracti"e strate.2# 96raditionall2' RHD ,as dia.nosed -2
auscultatin. for a %eart murmur in t%ose ,it% a%istor2of &R)#
Until t%e past decade' t%e stet%oscope ,as t%e
onl2nonin"asi"edia.nostic tool a"aila-le to p%2sicians in
lo,*income countries and in remote settin.s,%ere &R) and RHD
are most pre"alent# Ho,e"er' detection rates ,ere usuall2
lo,#Ec%ocardio.rap%2 %as pro"en to -e more sensiti"e and specific
t%an auscultation# RHDdetectedonec%ocardio.rap%2,it%out
anassociatedclinicall2pat%olo.ical
cardiacmurmurisreferredtoasit%t%ead"ent
ofporta-letec%nolo.2'ec%ocardio.rap%2canno,-eperformedat
arelati"el2lo,cost' e"eninremotesettin.s# 6%is de"elopment raises
t%e possi-ilit2 t%at people ,it% pre"iousl2undia.nosed RHD'
includin. t%ose ,it%out a 5no,n %istor2 of &R)' can -e
dia.nosedandsecondar2prop%2la8is startedat anearlier sta.eof
t%eillnesst%anpre"iousl2possi-le' t%us potentiall2 reducin.
mor-idit2 and mortalit2#9ETIOLOGYR%eumatic fe"er results from an
inflammator2 reaction to certain .roup & streptococcus-acteria#
6%e -od2 produces anti-odies to fi.%t t%e -acteria' -ut instead t%e
anti-odiesattac5 a different tar.et: t%e -od2?s o,n tissues# 6%e
anti-odies -e.in ,it% t%e 4oints andoften mo"e on to t%e %eart and
surroundin. tissues# 7ecause onl2 a small fraction (fe,ert%an 0#9@)
of people ,it% strep t%roat e"er contract r%eumatic fe"er' medical
e8pertssa2 t%at ot%er factors' suc% as a ,ea5ened immune s2stem'
must also -e in"ol"ed in t%ede"elopment of t%e
disease#;PATHOGENESIS0nteractions in"ol"in. streptococci and t%e
%ost pla2 an essential pat%o.enetic role forR) occurrence# Of t%e
A*%emol2tic streptococci t%at can produce infection in %umans'onl2
t%ose -elon.in. to .roup & can lead to R)' almost e8clusi"el2
after tonsillitis orp%arin.itis# One of t%e first mec%anism
proposed to e8plain in4ur2 in R) ,as a direct in*"asion of t%e
affected tissue -2 t%e !treptococcus# E"idence of a latenc2 period
of a-out9 ,ee5s -et,een t%e acute streptococcal in* fection and t%e
clinical appearance of tissuein4ur2 su..ests t%at tissue dama.e is
mediated -2 an immunolo.ical reaction ,it% an3autoimmune component#
(aplanand%is co,or5ers %a"e proposedt%e concept
ofBanti.enicmimicr2C: anti-odies produced-2t%estreptococcal
infectiona.ainst t%e-acterial anti.ens cross*react ,it% t%e %ost
tissues leadin. to tissue in4ur2# 6%edescription of t%e immunolo.ic
cross*reacti"it2 -et,een t%e $ protein and m2ocardialsarcolemma
lends support to t%is concept# &fter t%e immune reaction t%ere
is asu-se+uent inflammator2process in"ol"in.m2ocardiumand"al"ular
endocardium#>it%pro.ressionandpersis*tenceofinflammation "al"e
fi-rosis andcal* cificationmi.%t occur# 0t is e8timated t%at onl2
0#9@of indi"iduals ,it% an
untreatedstreptococcalp%ar2n.itis,illpresentanepisodeofR)#$oreo"erR)incidencefol*lo,in.
p%ar2n.itis in patients ,%o %a"e %ad a pre"ious episode of R) is
appro8imatel250@# 6%is o-ser"ation' to.et%er ,it% clinical studies
indicatin. a familiar clusterin. oft%e disease' su..ests t%at
.enetic factors mi.%t pla2 a role in t%e suscepti-ilit2 to R)#
0t%as -een reported t%e presence of specific 7*cell alloanti.en in
t%e DD@ of patients ,it%R) and in onl2 1;@ of controls# /enetic
suscepti-ilit2 to R) is also supported -2 t%eassocia* tion ,it%
HE&*DR2 and DR; anti.ens# 56%e pat%o.enesis of r%eumatic %eart
disease results froman immune responseconsistin. of %umoral and
cellular components after e8posure to !treptococcusp2o.enes
(classified as a .roup & streptococcus -2 t%e Eancefield
s2stem)' usuall2 aftera t%roat infection# 6%e precise
pat%op%2siolo.2 is o-scure -ut se"eral ad"ances %a"eno, -een
re"ie,ed# &nti.enic mimicr2 in association ,it% an a-normal
%ost
immuneresponseist%ecornerstoneofpat%op%2siolo.2'-asedont%etriadofr%eumato.enic.roup
& streptococcal strain' .eneticall2suscepti-le%ost' anda-errant
%ost immuneresponse#5!ome strains are more li5el2 to cause acute
r%eumatic fe"er t%an are ot%ers# ! p2o.enescontains $' 6' and R
surface proteins' ,%ic% are all associated ,it% -acterial
ad%erencetot%roat epit%elial cells# 6%er%eumato.enicit2of
somestreptococcus families
%astraditionall2-eenconsideredafeatureofstrains-elon.in.tospecific#
$serot2pes#Ho,e"er' data s%o, t%at r%eumato.enic $ serot2pes ,ere
infre+uentl2 identifi ed incommunities ,it% %i.% -urdens of acute
r%eumatic fe"er and r%eumatic %eart
disease#6%eseresults+uestiont%epotential importanceofot%er
diseasecausin.serot2pes'especiall2 t%ose t%at cause streptococcal
s5in infections' ,%ic% mi.%t -e implicated incases of acute
r%eumatic fe"er# 0n 1FFD' C%eadle noted t%at t%e c%ance of an
indi"idual4,it% a famil2 %istor2 of acute r%eumatic fe"er ac+uirin.
t%e disease is Bnearl2 fi"e timesas .reat as t%at of an indi"idual
,%o %as no suc% %ereditar2 taintC#/enerall2' HE& class00
molecules (,%ic% participate in anti.en presentation to 6*cell
receptors) seem to -emore closel2 associated ,it% an increased ris5
of acute r%eumatic fe"er or r%eumatic%eart disease t%an are class 0
molecules' alt%ou.% no sin.le HE&%aplot2pe orcom-ination%as
-eenconsistentl2associated,it%diseasesuscepti-ilit2#
6%ee8actmolecular mec%anism-2 ,%ic% HE&class 00 molecules
confer suscepti-ilit2 toautoimmune diseases is un5no,n# 6%e role of
autoimmune reactions in t%e pat%o.enesisof acute r%eumatic fe"er
,as su-stantiated ,%en anti-odies a.ainst .roup &streptococcus
reacted ,it% %uman %eart preparations#&fter -indin.tot%e
anti.enic peptide' t%e particular HE&comple8es
caninitiateinappropriate 6*cell acti"ation# $olecular mimicr2 ta5es
place -et,een streptococcal $protein and se"eral cardiac proteins
(cardiac m2osin' tropom2osin' 5eratin' laminin' and"imentin)' and
different patterns of 6*cell anti.en cross*reco.nition %a"e
-eenidentified#
CLINICAL FEATURESArthritis &rt%ritis is t%e most common
presentin. s2mptom of &R)' 2et dia.nosticall2 it can-et%e most
dicult# 0t is usuall2as2mmetrical and mi.rator2(one 4oint
-ecomin.in1amed as anot%er su-sides)' -ut ma2-e additi"e (multiple
4oints pro.ressi"el2-ecomin. in1amed,it%out ,anin.)#Ear.e4oints are
usuall2 aected'especiall2 t%e5nees and an5les# &rt%ritis of t%e
%ip is often dicult to dia.nose -ecause
o-4ecti"esi.nsma2-elimitedtoadecreasedran.eofmo"ement#
6%eart%ritisise8tremel2painful' oftenout ofproportiontot%eclinical
si.ns# 0t ise8+uisitel2responsi"etotreatment ,it% non*steroidal
anti*in1ammator2 dru.s (G!&0Ds)# 0ndeed't%is can -e auseful
dia.nostic feature' as art%ritis continuin. una-ated more t%an 9
da2s after startin.G!&0D t%erap2 is unli5el2 to -e due to
&R)# E+uall2' ,it%%oldin. G!&0Ds in patients,it%
mono*art%ral.ia or mono*art%ritis to o-ser"e t%e de"elopment of
pol2art%ritis canalso %elp in conHrmin. t%e dia.nosis of &R)#0n
t%ese patients' paracetamol or codeinema2 -e used for pain relief#
7ecause of t%e mi.rator2 and e"anescent nature of t%eart%ritis'
adeHnite%istor2ofart%ritis' rat%ert%andocumentation-2t%eclinician'
is5sucient to satisf2 t%is criterion# &R) s%ould al,a2s -e
considered in t%e dierentialdia.nosis of patients presentin.,it%
art%ritis in %i.%*ris5 populations# 0nt%e %ospitalsettin.'
p%2sicians and sur.eons s%ould colla-orate ,%en t%e dia.nosis of
art%ritis isunclear#Patients,it%sterile4oint
aspiratess%ouldne"er-etreatedspeculati"el2forseptic art%ritis
,it%out furt%er in"esti.ation' particularl2 in areas ,it% %i.%
&R)IRHDpre"alence# $ono*art%ritis or pol2art%ral.ia is a common
manifestation of &R)' and isoften associated ,it% o"ert or
su-clinical carditis# 0n t%ese populations' aseptic mono*art%ritis
or pol2art%ral.iama2-econsideredas ama4or manifestation'
inplaceofpol2art%ritis# Ho,e"er' alternati"e dia.noses s%ould-e
carefull2e8cluded# $ono*art%ritis ma2 also -e t%e presentin.
feature if anti*in1ammator2 medication iscommenced earl2 in t%e
illness prior to ot%er 4oints -ecomin. in1amed# 1Sydenhams chrea
6%is manifestation aects females predominantl2' particularl2 in
adolescence# C%oreaconsists of 4er52' uncoordinated mo"ements'
especiall2 aectin. t%e %ands' feet' ton.ueandface# 6%e mo"ements
disappear durin.sleep# 6%e2ma2aect oneside onl2(%emic%orea)# Useful
si.ns include:J 6%e Bmil5maid=s .ripC (r%2t%mic s+ueeKin. ,%en t%e
patient .rasps t%e e8aminer=sHn.ers)J B!poonin.C (1e8ion of t%e
,rists and e8tension of t%e Hn.ers ,%en t%e %ands aree8tended)J 6%e
Bpronator si.nC (turnin. out,ards of t%e arms and palms ,%en %eld
a-o"e t%e%ead) and J 0na-ilit2 to maintain protrusion of t%e
ton.ue#7ecause c%orea ma2 occur after a prolon.ed latent period
follo,in. .roup &streptococcus (/&!) infection' t%e
dia.nosis of &R) under t%ese conditions does notre+uire t%e
presence of ot%er manifestations or ele"ated plasma streptococcal
anti-od2titres#Patients,it%pure c%oreama2%a"e mildl2 ele"ated
er2t%roc2te sedimentationrate (E!R' appro8 ;0mmI%r)' -ut %a"e a
normal serum C*reacti"e protein (CRP) le"eland ,%ite cell count#
C%orea is t%e &R) manifestation most li5el2 to recur' and is
often6associated ,it% pre.nanc2 or oral contracepti"e use# 6%e "ast
ma4orit2 of cases resol"e,it%inmont%s (usuall2 ,it%in,ee5s)'
alt%ou.% rare cases lastin. as lon. as 9 2ears%a"e -een documented#
1Carditis <%ou.% pericarditis and m2ocarditis ma2 occur'
cardiac in1ammation in &R) almostal,a2s aects t%e "al"es'
especiall2 t%e mitral and aortic "al"es# Earl2 disease usuall2leads
to "al"ular re.ur.itation# >it% prolon.ed or recurrent disease'
scarrin. ma2 leadto stenotic lesions# &cute carditis usuall2
presents clinicall2 as an apical %olos2stolicmurmur ,it% or ,it%out
a mid*diastolic 1o, murmur (Care2 Coom-s murmur)' or
anearl2diastolicmurmurat t%e-aseoft%e%eart (aorticre.ur.itation)#
6%er%eumaticaetiolo.2canusuall2-e conHrmed-2a t2pical appearance
onec%ocardio.rap%2#Con.esti"e %eart failure in &R) results
from"al"ular d2sfunction secondar2 to"al"ulitis' and is not due to
primar2 m2ocarditis# 0f pericarditis is present' t%e frictionru-
ma2 o-scure "al"ular murmurs#1S!"c!tane!s nd!#es 6%ese are "er2
rare (less t%an 2@ of cases)# 6%e2 are 0#5:2#0cm in diameter'
round'Hrm' freel2 mo-ile and painless nodules t%at occur in crops
of up to 12 o"er t%e el-o,s',rists' 5nees'
an5les'&c%illestendon' occiput andposteriorspinal
processesoft%e"erte-rae# 6%e2 tend to appear 1:2 ,ee5s after t%e
onset of ot%er s2mptoms' last onl21:2 ,ee5s (rarel2 more t%an 1
mont%) and are stron.l2 associated ,it% carditis#1 Erythema
mar$inat!m Er2t%ema mar.inatum is also rare# &s ,it%
su-cutaneous nodules' er2t%ema mar.inatumis %i.%l2 speciHc for
&R)# 0t occurs as -ri.%t pin5 macules or papules t%at -lanc%
underpressure andspreadout,ardsin a circularor serpi.inous pattern#
6%eras% can-edicult to detect in dar5*s5inned people' so close
inspection is re+uired# 6%e lesionsare not itc%2 or painful' and
occur on t%e trun5 and pro8imal e8tremities -ut almostne"er on t%e
face# 6%e ras% is not aected -2 anti* in1ammator2 medication' and
ma2recur for ,ee5s or mont%s' despite resolution of t%e ot%er
features of &R)# 6%e ras% ma2-e more apparent after
s%o,erin.#17Arthra#$ia &rt%ral.ia is a non*speciHc s2mptom' and
usuall2occurs in t%e same pattern asr%eumatic pol2art%ritis
(mi.rator2' as2mmetrical' aectin.lar.e4oints)#
<ernati"edia.noses s%ould -e considered in a patient ,it%
art%ral.ia t%at is not t2pical of &R)#1Fe%er >it% t%e
e8ception of c%orea' most manifesta* tions of &R) are
accompanied -2 fe"er#Earlier reports of fe"er descri-ed pea5
temperatures commonl2 .reater t%an 9DLC' -utlo,er .rade
temperatures %a"e -een descri-ed more recentl2# &s t%ere are no
recentdata relatin. to fe"er in lo,*ris5 populations' it is
recommended t%at an oral' t2mpanicor rectal temperature .reater
t%an 9FLC on admission' or documented durin. t%e currentillness'
s%ould-econsideredasfe"er(Ee"el 0M'/radeC)#
)e"er'li5eart%ritisandart%ral.ia' is usuall2 +uic5l2 responsi"e to
salic2late t%erap2#1 E#e%ated ac!te&'hase reactants 62picall2'
&R) patients %a"e a raised serum CRP le"el and E!R# 6%e
perip%eral ,%ite-lood cell count is N15O10DIE in P5@ of patients'
so an ele"ated ,%ite cell count is aninsensiti"e mar5er of
in1ammation in &R)# )urt%er anal2sis of t%ese data
demonstratedt%at less t%an ;@ of patients ,it% conHrmed &R)'
e8cludin. c%orea' %ad -ot% a serumCRP le"el ofN90m.IE and an E!R of
N90mmI%r# 6%erefore' it is recommended t%at aserumCRP le"el
ofQ90m.IE
orE!RofQ90mmI%risneededtosatisf2t%eminorcriterionofele"atedacute*p%asereactants#6%eserumCRP
concentrationrisesmorerapidl2 t%an t%e E!R' and also falls more
rapidl2 ,it% resolution of t%e attac5# 6%e E!Rma2 remain ele"ated
for 9: mont%s' despite a muc% s%orter duration of s2mptoms#1
Pr#n$ed P&R inter%a# and ther rhythm a"nrma#ities !ome %ealt%2
people s%o, t%is p%enomenon' -ut a prolon.ed P*R inter"al t%at
resol"eso"er t%e ensuin. da2s to ,ee5s ma2 -e a useful dia.nostic
feature in cases ,%ere t%eclinical featuresarenot deHniti"e#
E8tremeHrst*de.ree-loc5sometimesleadstoa4unctional r%2t%m' usuall2
,it% a %eart rate similar to t%e sinus rate# !econd*de.ree' ande"en
complete %eart -loc5' can occur and'if associated ,it% a slo,
"entricular rate'ma2 .i"e t%e false impression t%at carditis is not
si.niHcant#& small proportion %ad8more se"ere conduction
a-normalities' ,%ic% ,ere sometimes found -2 auscultation
orec%ocardio.rap%2 in t%e a-sence of e"idence of "al"ulitis#1
6%erefore' anelectrocardio.ram(EC/) s%ould-eperformedinall cases of
suspected&R)0f aprolon.edP*R inter"al isdetected't%eEC/
s%ould-erepeated after1:2 mont%s todocument a return to normal#0f
it %as returned to normal' &R) -ecomes a more li5el2dia.nosis#
6%e P*R inter"al increases normall2 ,it% a.e#1DIAGNOSIS&ccurate
dia.nosis of &R) is important# O"er dia.nosis results in
unnecessar2treatment o"er alon.time' ,%ileunder*dia.nosis leads
tofurt%er attac5s of &R)'cardiac dama.e and premature deat%#
Dia.nosis remains a clinical decision' as t%ere isno speciHc
la-orator2 test# 6%e dia.nosis of &R) is usuall2 .uided -2 t%e
Rones criteriaand t%e more recent >orld Healt% Or.aniKation
(>HO) criteria#16%e Rones criteria for t%e dia.nosis of &R)
,ere introduced in 1D;;# 6%e criteria di"idet%e clinical features
of &R)intoma4or andminor manifestations' -asedont%eirpre"alence
and speciHcit2# $a4or manifestations are t%ose t%at ma5e t%e
dia.nosis moreli5el2' ,%ereas minor manifestations are considered
to -e su..esti"e' -ut insucient ont%eir o,n' for a dia.nosisof
&R)# 6%e e8ception to t%is is in t%e dia.nosis of
recurrent&R)#1910(OR) UPThrat c!#t!re6%roat culture findin.s
for .roup & -eta %emol2tic Streptococcusare usuall2 ne.ati"e-2
t%e time s2mptoms of r%eumatic fe"er or r%eumatic %eart disease
appear# &ttemptss%ould -e made to isolate t%e or.anism -efore
t%e initiation of anti-iotic t%erap2 to %elpconfirm a dia.nosis of
streptococcal p%ar2n.itis and to allo, t2pin. of t%e or.anism if
itis isolated successfull2# PRa'id anti$en detectin test6%is test
allo,s rapid detectionof .roup&streptococcal anti.enandallo,s
t%edia.nosis of streptococcal p%ar2n.itis and t%e initiation of
anti-iotic t%erap2 ,%ile t%epatient is still in t%e p%2sician?s
office# 7ecause t%e rapid anti.en detection test %as aspecificit2
of .reater t%an D5@ -ut a sensiti"it2 of onl2 0*D0@' a t%roat
culture s%ould-e o-tained in con4unction ,it% t%is test#
PAntistre'tccca# anti"dies6%eclinical
featuresofr%eumaticfe"er-e.inat t%etimeantistreptococcal
anti-od2le"els are at t%eir pea5# 6%us' antistreptococcal anti-od2
testin. is useful for confirmin.pre"ious .roup &streptococcal
infection# 6%e ele"ated le"el of antistreptococcalanti-odies is
useful' particularl2in patients t%at present ,it% c%orea as t%e
onl2dia.nosticcriterion# !ensiti"it2forrecent
infectionscan-eimpro"ed-2testin.forse"eral anti-odies#
&nti-od2titers s%ould-ec%ec5ed at 2*,ee5inter"als in order
todetect a risin. titer#P6%e most common e8tracellular
antistreptococcal anti-odies tested includeantistreptol2sin O
(&!O)' antideo82ri-onuclease (DG&se) 7'
anti%2aluronidase'antistrepto5inase' antistreptococcal esterase'
and anti*DG &nti-od2 tests for cellularcomponents of .roup
& streptococcal anti.ens include antistreptococcal
pol2sacc%aride'antiteic%oic acid anti-od2' and anti:$ protein
anti-od2# P0n .eneral' t%e ratio of anti-odies to e8tracellular
streptococcal anti.ens rises durin. t%efirst mont% after infection
and t%en plateaus for 9* mont%s -efore returnin. to normal11le"els
after *12 mont%s# >%en t%e &!O titer pea5s (2*9 ,5 after t%e
onset of r%eumaticfe"er)' t%e sensiti"it2 of t%is test is F0*F5@#
6%e anti*DG&se 7 %as a sli.%tl2 %i.%ersensiti"it2 (D0@) for
detectin. r%eumatic fe"er or acute
.lomerulonep%ritis#&nti%2aluronidaseresultsarefre+uentl2a-normalinr%eumaticfe"erpatients,it%anormal
le"el of &!O titer and ma2 rise earlier and persist lon.er t%an
ele"ated &!Otiters durin. r%eumatic fe"er#PAc!te 'hase
reactants6%eC*reacti"eproteinander2t%roc2tesedimentationrateareele"atedinr%eumaticfe"er
due to t%e inflammator2 nature of t%e disease# 7ot% tests %a"e a
%i.% sensiti"it2-ut lo, specificit2 for r%eumatic fe"er# 6%e2 ma2
-e used to monitor t%e resolution ofinflammation' detect relapse
,%en ,eanin. aspirin' or identif2 t%e recurrence ofdisease# PHeart
reacti%e anti"diesTropomyosin is elevated in acute reumatic fever!
7TREAT*ENT0ntramuscular 7enKat%ine penicillin/andoral
PenicillinMare t%e recommendedantimicro-ial dru.sfort%etreatment
of/&!# E8ceptinindi"idual,it%%istoriesofpenicillin aller.2#
F6%e oralanti-iorics of c%oice arepenicillin M
andamo8icillin#/enerall2' 250 m.2times dail2 is recommended for
most c%ildren# & dose of 500 m. 2 to 9 imes dail2 isrecommended
for adolescents and adults# &ll patient s%ould continue to ta5e
penicillinre.ular2 for an entire 10 da2 period e"en t%ou.% t%e2
li5el2 ,ill -e as2mptomatic aftert%e first fe, da2s# Penicillin M
is preferred to penicillin / -ecause it is more resistant to.astric
acid# F7enKat%ine penicillin / s%ould -e considered particularl2
for patients ,%o are unli5el2to complete a 10 da2 course of oral
t%erap2 and for patients ,it% personal of famil2%istories of
r%eumatic fe"er or r%eumatic %eart disease or en"ironmental factors
(suc% ascro,ded li"in. condition or lo, socioeconomic status) t%at
place t%em at en%anced ris5for r%eumatic fe"er# 7enKat%ine
penicillin / s%ould -e .i"en as a sin.le in4ection in a12lar.e
muscle mass# 6%is formulation is painful' in4ection t%at contain
procaine
penicillin0nadditionto-enKat%inepenicillin/arelesspainful#6%erecommendeddosa.eof-enKat%inepenicillin/is00#000U0$forpatient
,%o,ei.%t 2P5.orlessand1#200#000 U for patient ,%o ,ei.%t more t%an
2P 5.# t%e com-ination of D00#000 U of-enKat%ine penicillin / and
900#000 U of procaine penicillin / is satisfactor2 t%erap2for most
smaller c%ildren# 6%e efficac2 of t%is com-ination for %ea"ier
patient suc% aslar.e teena.ers or adult re+uires furt%er stud2#
&ller.ic reactions to penicillin are morecommon in adults t%an
in c%ildren# F6%ere%as -eennosi.nificant c%an.e int%e mana.ement of
acute R)in t%elast 502ears# Patientsneedpenicillinto
eradicate/&! present in t%roat# &ntiinflammator2a.ents *
aspirin or steroids * are used to control r%eumatic acti"it2#
&spirin or steroids donot cure R)# 6%ese suppress t%e
inflammator2 response ,%ic% lasts for a-out 12 ,5 inmore t%an F0
per cent patients# Hence' t%e standard dose of aspirin (D0*120
m.I5.Ida2)is .i"en for ten ,ee5s and tapered in t%e ne8t t,o ,ee5s#
6%e dose of prednisone 0m.Ida2 a-o"e 20 5. and ;0 m. Ida2 -elo, 20
5. in ,ei.%t is .i"en for t%ree ,ee5s andtapered in t%e ne8t nine
,ee5s# 6%e standard 12 ,ee5 course can -e reduced to four toei.%t
,ee5s dependin. on t%e patient=s response#
Patients ,it%out carditis can %a"e ,ee5l2 follo, up of E!R and
CRP# 0f t%e2 normaliKe't%e course can -e reduced to a s%orter
period# &spirin is preferred o"er steroids as lon.as t%e
carditis is mild and t%e patient is not in con.esti"e failure#
Ho,e"er' ,it% se"erecarditis and con.esti"e failure steroid is t%e
dru. of c%oice -ecause of t%e more potentsuppressi"e effect#
Gon*steroidal anti*inflammator2 dru.s (G!&0Ds) %a"e not -een
s2stematicall2 utiliKedto esta-lis% t%eir usefulness#
0mmunosuppressi"e a.ents li5e aKat%ioprine andc2closporine &
%a"ealso-eenconsideredforacuter%eumaticfe"er#Despiteoft%econcerns
of side effects'to8icit2andlate onset of l2mp%omas ,it%t%e use of
t%eseimmunosuppressi"e it is possi-le to ar.ue t%at a s%ort course
ofto F ,5 ma2 result ina .reater -enefit t%an %arm# Ho,e"er' most
et%ics committees ,ill %esitate to permits2stematic testin. of
t%ese a.ents#
0t is no, ,ell accepted t%at r%eumatic endocarditis in"ol"in.
%eart "al"es is t%e maincauseof mor-idit2andmortalit2inR)# !ur.ical
mana.ement consistin.of mitraland Ior aortic "al"e replacement in
patients ,%ose con.esti"e failure cannot -e13controlled-2a..ressi"e
medical treatment durin.acute R)' is life sa"in.# 0t t%econ.esti"e
failure cannot -e controlled ,it% ma8imal medical t%erap2 and t%e
patient isdeterioratin. due to mitral re.ur.itation' mitral "al"e
replacement durin. acti"e R) isindicated# 0n spite of clinical
e"idence for acti"e R)' t%e %eart siKe returns to normal
andcon.esti"e failure disappears' confirmin. t%at r%eumatic
m2ocarditis pla2s little or norole in t%e mortalit2 of R)#
$ana.ement of c%orea: 0t %as a self limitin. course' %ence
parents need
reassurance#6%ec%ildrencould-ereated,it%sedati"esli5ep%eno-ar-itone90m.t%ricedail2#c%lorpromaKine'
"alium'dip%end2dramineorpromet%aKinecan -eused as
sedati"es#Haloperidol 5to10m.t,icedail2%as-eenusedeffecti"el2#
<%ou.%aspirinandsteroids are not supposed to %a"e a place in
t%e treatment of c%orea' some patients %a"es%o,n dramatic response
to steroids' if t%e2 do not s%o,ade+uate response tosedati"es#
!ince' lon. term follo, up of c%orea patients %a"e identified
su-clinical carditis in 20 to90 per cent patients' penicillin
prop%2la8is is essential and s%ould -e continued on alon. term
-asis# R%eumatic %eart disease: !ur.ical mana.ement of "al"e
disease ,ast%estandardapproac%till -alloonmitral
"al"otom2,asintroducedin1DF5# $itralstenosis could -e corrected
sur.icall2 eit%er -2 closed "al"otom2' opencommissurotom2 or -2
"al"e replacement if t%e "al"e ,as calcified# 7alloon
"al"otom2pro"ides results as .ood as sur.ical "al"otom2 and %as
-ecome t%e treatment of c%oicein spite of -ein. more e8pensi"e# )or
mitral re.ur.itation t%e c%oice of treatment ,ould-e "al"e repair
especiall2 in 2oun.er patients to a"oid lon.*term anti*coa.ulant
t%erap2#$ost patients ,it% mitral or aortic "al"e re.ur.itation end
up ,it% "al"e replacement#Hence' alt%ou.% sur.ical %elp is "er2
useful it is e8pensi"e and re+uires prolon.ed care,it%
anticoa.ulant t%erap2 ,it% t%e associated complications of "al"e
t%rom-osis ands2stemic em-olic disasters especiall2 in t%e
lo,*income population of t%e countr2#
O"eralon.follo,upperiodrelati"el2fe,patientsremainfreeofe"ent#
7alloonmitral"al"otom2%as -een utiliKed in t%e paediatric patients
-elo,1*2 2r in a.e ,it%accepta-le results# 0t %as -een e8tended to
patients of mitral stenosis#
PERICARDIAL EFFUSIONINTRODUCTION14Pericardial
effusionist%epresenceof ana-normal amount of andor
ana-normalc%aracter to fluid in t%e pericardial space# 0t can -e
caused -2 a "ariet2 of local ands2stemic disorders' or it ma2 -e
idiopat%ic#DPericardial effusions can -e acute or c%ronic' and t%e
time course of de"elopment %as a.reat impact on t%e patient?s
s2mptoms# 6reatment "aries' and is directed at remo"al oft%e
pericardial fluid and alle"iation of t%e underl2in. cause' ,%ic%
usuall2 is determined-2 a com-ination of fluid anal2sis and
correlation ,it% comor-id illnesses#DPericardial effusion is a
common findin. in clinical practice eit%er as incidental findin.or
manifestation of a s2stemic or cardiac disease# 6%e spectrum of
pericardial effusionsran.es from mild as2mptomatic effusions to
cardiac tamponade# $oreo"er' pericardialeffusion ma2 accumulate
slo,l2 or suddenl2#DUnfortunatel2' t%ere are fe, epidemiolo.ical
data on t%e incidence and pre"alence ofsuc% effusions in t%e
clinical settin.# 0n $aria Mittoria %ospital' an ur-an .eneral
ospitalin6orino andan0talianreferral centre for pericardial
diseases' t%e meanannualincidence and pre"alence of pericardial
effusion %a"e -een' respecti"el2' 9 and D@ in aSears e8perience of
t%e ec%o la-orator2#10!uc% data mainl2 depend on t%e
epidemiolo.ical -ac5.round (especiall2 de"eloped
"s#de"elopin.countr2',%eretu-erculosisisaleadin.causeofpericardial
diseaseandconcurrent H0Minfectionma2%a"eanimportant promotin.role)'
t%einstitutionalsettin. (tertiar2 referral centre "s# secondar2 and
.eneral %ospitals)' and t%e a"aila-ilit2of specific su-specialties
(especiall2 nep%rolo.2' r%eumatolo.2' and oncolo.2)# 10ETIOLOGY
& ,ide "ariet2 of aetiolo.ic a.ents ma2 -e responsi-le of
pericardial effusions' since all5no,n causes of pericardial disease
ma2 -e causati"e a.ents# 6%e more common causesof pericardial
effusions include infections ("iral' -acterial'
especiall2tu-erculosis)'Cancer' connecti"e tissue diseases'
pericardial in4ur2 s2ndromes (post*m2ocardialinfarction effusions'
post*pericardiotom2 s2ndromes' post*traumatic Pericarditis
eit%eriatro.enic or not)' meta-olic causes (especiall2
%2pot%2roidism' renal failure)'m2opericardial diseases
(especiall2pericarditis' -ut alsom2ocarditis' %eart
failure)'15aortic diseases' especiall2 aortic dissection e8tendin.
into t%e pericardium' and selecteddru.s (i#e# mino8idil)#
H2dropericardium' a non*inflammator2 transudati"e
pericardialeffusion' ma2 occur not onl2 in %eart failure' -ut also
s2ndrome' ,%en !tarlin.
forcespromotet%eaccumulationofaplasmaultrafiltrateacrosst%epericardiumas,ellasot%er
mem-ranes (e#.# pleura and peritoneum)# 100n t%e last 20 2ears'
fi"e ma4or sur"e2s %a"e -een pu-lis%ed on t%e c%aracteristics
ofmoderate to lar.e pericardial effusions# O-"iousl2' t%e relati"e
fre+uenc2 of differentcauses depends on t%e local epidemiolo.2
(especiall2 t%e pre"alence of tu-erculosis)'t%e %ospital settin.'
and t%e dia.nostic protocol t%at %as -een adopted# $an2 cases
stillremainidiopat%icinde"elopedcountries(upto50@)' ,%ileot%er
commoncausesinclude especiall2 cancer (10:25@)' pericarditis and
infectious causes (15:90@)'iatro.enic causes (15:20@)' and
connecti"e tissue disease (5:15@)' ,%ereastu-erculosis is t%e
dominant cause in de"elopin. countries (0@)' ,%ere tu-erculosis
isendemic#0n t%e settin. of pericarditis ,it% pericardial effusion'
t%e pre"alence ofmali.nant or
[email protected]%edseries
ad"anced %2poal-uminaemia' suc% as in cirr%osis and
nep%ritic#10166a-le# Etiolo.2 Pericard Effusion17PATHOGENESIS6%e
normal pericardial sac contains 10:50 mE of pericardial 1uid actin.
as alu-riHcant -et,een t%e pericardial la2ers# !urprisin.l2' little
is 5no,n a-out t%eformation and remo"al of pericardial 1uid'
-ecause of t%epaucit2ofcompre%ensi"estudies'
especiall2in%umansu-4ects' andmet%odolo.ical difHculties
todistin.uis%-et,een t%e d2namics of normal pericardial 1uid and
t%ose of a pat%olo.ical effusion#Ge"ert%eless' normal pericardial
1uid is .enerall2 considered an ultraHltrate of
plasma#6%earran.ement
ofl2mp%atic"esselsiscomple8and%as-eendescri-edin%umancada"ers# 6%e
l2mp%atic "essels include different pat%,a2s accordin. to "entral'
lateral'and posterior surfaces'-ut' in an2 case' terminate to
mediastinal' trac%eo-ronc%ial' oriu8* taesop%a.eal l2mp% nodes# On
t%e "entral surface' t%e l2mp%atics of t%e parietalpericardium
connect to l2mp%atics in t%e pericardial fat and areolar tissue# On
t%e lateralandposterior surfaces' t%el2mp%atics of t%eparietal
pericardiumanastomose,it%l2mp%atics of t%e re1ected mediastinal
pleura# E2mp%atic draina.e of t%e pericardium tot%e mediastinal and
trac%eo-ronc%ial l2mp% nodes and interactions ,it% pleural
pro"idet%e anatomical -asis for pat%olo.ical in"ol"ement of t%e
pericardiumin speciHcdiseases (i#e# pleuro*pulmonar2diseases suc%as
pulmonar2tu-erculosis andlun.cancer)# 11&n2pat%olo.ical
processusuall2causesanin1ammator2process,it%t%epossi-leincreasedproductionofpericardial
1uid(e8udate)#&nalternati"emec%anismoft%eformationofperi*cardial
1uidma2-et%edecreasedrea-sorptionduetoincreaseds2stemic "enous
pressure .enerall2 as a result of con.esti"e %eart failure or
pulmonar2%2pertension (transudate)# 0f pericardial 1uid is free to
mo"e ,it%in t%e pericardial sacfollo,in. t%e .ra"it2forces' it
usuall2starts accumulatin. posteriorl2to t%e left"entricle ,%en t%e
patient is la2in. on %isI%er left side for ec%ocardio.rap%ic
e"aluation(mildeffusiondetectedinitiall2as posterior)'
t%encircumferentiall2int%ecaseofmoderate to lar.e pericardial
effusions# & mild pericardial effusion ma2 also -e
detectedclose to t%e ri.%t atrium -ecause t%is is t%e cardiac
c%am-er ,it% t%e lo,est pressures,it%in t%e cardiac c2cle and t%us
pericardial 1uid accumulation is easier in t%is
position#&nisolatedmildanterior pericardial 1uidis unusual
onec%ocardio.rap%2,it%outpre"ious pericardial scarrin. as follo,in.
sur.er2 or c%ronic pericarditis' and s%ould -ere.arded as fat
rat%er t%an pericardial 1uid#
1118Computedtomo.rap%2(C6)orcardiacma.neticresonance(C$R)ma2conHrmt%eHndin.inspeciHccases#
Ont%econtrar2afterpericardial scarrin.(i#e# aftercardiacsur.er2 or
c%ronic pericarditis' or -acterial infections)' pericardial 1uid
ma2 not %a"e auniformdistri-ution ,it%in t%e pericardial space and
ma2 .i"e rise to loculatedeffusions t%at s%ould -e e"aluated ,it%
multiple cardiac "ie,s# 6%e pressure "olumecur"eof t%enormal
pericardiumisaR*s%apedcur"e: after aninitial s%ort
s%allo,portiont%at allo,s
t%epericardiumtostretc%sli.%tl2inresponsetop%2siolo.icale"ents'
suc% as c%an.es in posture or "olume status' ,it% minimal pressure
increase't%en t%e pericardium does not allo, furt%er sudden
increases of t%e "olume ,it%out amar5ed increase in t%e
intrapericardial pressure# 6%us a sudden increase of
pericardial"olume of 100:200 mE' as in %aemopericardium' ma2
ele"ate pericardial pressure till20:90 mmH. ,it% acute cardiac
tamponade (acute or sur.ical cardiac tamponade)# Ont%e contrar2 a
slo,l2 accumulatin. pericardial 1uid ma2 allo, pericardial
distention tillt%eaccumulationof 1:2Eof pericardial 1uid,it%out
t%ede"elopment of
cardiactamponadetillad"ancedsta.esoften-ecauseofintercurrente"ents(c%roniccardiactamponade
or medical cardiac tamponade)#11CLINICAL *ANIFESTATION6%eclinical
presentationofpericardial
effusionis"ariedaccordin.tot%espeedofpericardial 1uid accumulation
as mentioned in t%e introduction' and t%e aetiolo.2 of t%eeffusion
,it% possi-le s2mptoms t%at ma2 -e related to t%e causati"e
disease# 6%e rateof pericardial 1uid accumulation is critical for
t%e clinical presentation# 0f pericardial1uid is +uic5l2
accumulatin. suc% as for ,ounds or iatro.enic perforations'
t%ee"olution is dramatic and onl2 small amounts of -lood are
responsi-le of a +uic5 rise ofintrapericardial pressureando"ert
cardiactamponadeinminutes# Ont%econtrar2aslo,l2 accumulatin.
pericardial 1uid allo,s t%e collection of a lar.e effusion in da2s
to,ee5s -efore asi.niHcant increaseinpericardial pressure-ecomes
responsi-leofs2mptoms and si.ns# 9 Classical s2mptoms include
d2spnoea on e8ertion pro.ressin. toort%opnoea'c%est pain'andIor
fullness# &dditional occasional s2mptoms due to
localcompressionma2include nausea (diap%ra.m)' d2sp%a.ia
(oesop%a.us)' %oarseness(recurrent lar2n.eal ner"e)' and %iccups
(p%renic ner"e)# GonspeciHc s2mptoms includealsocou.%' ,ea5ness'
fati.ue' anore8iaandpalpitationsandre1ect t%ecompressi"e19effect of
t%e pericardial 1uidonconti.uous anatomic structures or
reduced-loodpressure and secondar2 sinus tac%2cardia#106%e
classical Hndin.s of cardiac tamponade %a"e -een descri-ed -2t%e
t%oracicsur.eon 7ec5 in 1D95# 7ec5 identiHed a triad includin.
%2potension' increased 4u.ular"enouspressure'
andasmalland+uiet%eart#6%istriad,asclassicall2identiHedinit%
in1amedpericardium' t%e patient usuall2 %as t%e com-ination of
effusion and pericardialt%ic5enin.# On C6' .enerall2' pericardial
effusions are of lo, densit2 in t%e ran.e of 0:20 HounsHeld units
(HU)# >%en t%e effusion contains %i.%er amounts of protein'
suc%as in -acterial infections' or ,%en it is %aemorr%a.ic' its
densit2 ma2 rise to 50 HU andmore# 0n1amed pericardium ma2 also
s%o, contrast en%ancement# 0n C6 ima.in. of t%epericardium'
difHcult2ma2-e encountered in
differentiatin.1uidfromt%ic5enedpericardial tissue# Cardiac
ma.netic resonance is superior to C6 in differentiatin.
1uid'especiall2%i.%l2proteinaceouse8udati"eeffusions'
fromt%ic5enedpericardium# Ont%econtrar2'C6ma2detect e"enminimal
amountsofpericardial calcium' ,%ereasC$Rma2miss si.niHcant
deposits# Computedtomo.rap%2re+uires less timet%anec%ocardio.rap%2
and C$R# Ho,e"er' C6 re+uires t%e use of intra"enousl2administered
iodinated contrast materials and ioniKin. radiation# $oreo"er' if
performed,it%out EC/ .atin.' C6 ma2 lead to cardiac motion
artefacts' t%at limit t%e e"aluationof pericardial t%ic5ness#
Ho,e"er' t%e use of more recent and updated C6 scanners ,it%a
.reater spatial and temporal resolution and more sop%isticated
al.orit%ms for ima.ereconstructionma2allo,a si.niHcant
reductioninC6ima.in.artefacts# Cardiacma.netic resonance%as
asuperior a-ilit2toc%aracteriKe pericardial effusions
andmasses,it%t%euseof acom-inationof 61,ei.%ted' 62*,ei.%ted'
and.radient*recalledec%ocinese+uences,it%outt%euseofeit%eriodinatedcontrastmaterialorioniKin.
radiation# Ho,e"er' a possi-le disad"anta.e of C$R ,it% EC/ .atin.
is t%at23arr%2t%mias' often associated ,it% m2opericardial
diseases' ma2 cause artefacts#¬%er disad"anta.e of C$R is
related to its limited a"aila-ilit2 and %i.%er costs# Useof i#"#
in4ected .adolinium ma2 -e useful for pericarditis detection'
-ecause .adolinium%as-eenreportedtoen%ancein1amedpericardium'
as,ell asfor t%edetectionofconcomitant m2ocardial in"ol"ement in
m2opericarditis#1024)i.urePresentationofamild(&)"s#
moderatetolar.epericardialeffusions(7)onec%ocardio.rap%2# $ild
pericardial effusion is e"ident ad4acent to t%e ri.%t atrium
infour*c%am-ers "ie,andonl2posterior inparasternal lon.*a8is
"ie,(&)# &s 1uidaccumulates'
t%eeffusion-ecomescircumferential (7)# Pe' pericardial effusionV
R&'ri.%t atriumV &o' aorta#10TREAT*ENT!2mptoms andsi.ns
su..esti"e of pericardial in"ol"ement ma2-e t%e presentin.clinical
feature of eit%er primar2 or secondar2 mali.nant cardiac disease'
-ut t%e2 aremuc% more fre+uentl2 present in patients under
treatment for ad"anced mali.nanc2# Eifee8pectanc2 is s%ort as
concomitant metastases are nearl2 al,a2s present else,%ere# 0nt%ese
instances' ade+uate mana.ement of pericardial effusion ma2
contri-ute topalliation of t%e s2mptoms3ina si.nificant num-er of
patients3andpossi-l2toprolon.edsur"i"al
(inanundefinednum-erofcases)#<%ou.%t%emaincausesofdeat% in
patients ,it%mali.nanc2are unrelated tocardiac in"ol"ement'
insomenecrops2 series pericardial metastases are commonl2 found'
particularl2 in lun. cancer(95@) and -reast cancer (25@) on t%e
ot%er %and' cardiac s2mptoms are mainl2
relatedtot%epresenceoftamponade' ,%ic%ispresent inasi.nificant
num-erofpatients'25alt%ou.% it %as no ne.ati"e impact on sur"i"al
if it is correctl2 mana.ed# 0n patients ,it%mali.nanc2 and
pericardial effusion t%e first step is to determine ,%et%er t%e
effusion issecondar2 to neoplastic pericardial in"ol"ement or if it
is an epip%enomenon(non*mali.nant effusion)relatedtot%emana.ement
oft%ecancer(suc%aspre"ioust%oracic irradiation) or effusions of
un5no,n ori.in# 0n t%ese t,o latter situations' anin"asi"e
procedure ma2 -e ,arranted in t%e a-senceof tamponadeas t%e
dia.nostic2ield of -ot% pericardial fluid and tissue is %i.% for
mali.nanc2# 6%e mana.ement
ofcardiactamponadeinpatients,it%secondar2neoplasticpericardial
in"ol"ement%ast,otar.ets3relief of s2mptoms' andpre"entionof
recurrences# Pericardiocentesisalle"iates s2mptoms in most cases#
0t is a safe' simple' and ,idel2 a"aila-le procedure,it% fe,
complications if it is done under ec%ocardio.rap%ic .uidance#
Pro-a-l2 it ist%e procedure of c%oice in end sta.e patients' ,%en
recurrence of effusion is not a realissue# 0n patients sur"i"in.
lon.er t%e pericardial fluid ma2 re*accumulate' and
isolatedpericardicentesis pre"ents t%is in onl2 a-out 50@ of cases#
110n suc% patients a more a..ressi"e approac% ,it% sur.er2 ma2 -e
,arranted#Patientmana.ement %as to -e indi"idualiKed (t2pe and
sta.e of neoplasm' .eneral condition'etc) as e"en t%e -est possi-le
treatment for responsi"e t2pes of tumour (for e8ample'l2mp%oma)
,it% neoplastic pericardial in"ol"ement is associated ,it% sur"i"al
of onl2a-out one 2ear#116%et%erap2of pericardial
effusions%ould-etar.etedat t%eaetiolo.2asmuc%aspossi-le# 0n 0@ of
cases' t%e effusion is associated ,it% a 5no,n disease' 1F and
t%eessential treatment is t%at of t%e underl2in.disease#
>%enpericardial effusionisassociated ,it% pericarditis'
mana.ement s%ould follo, t%at of pericarditis#Ge"ert%eless' ,%en
dia.nosis is still unclear or idiopat%ic' and in1ammator2
mar5ersare ele"ated' a trial of aspirin or a nonsteroidal
anti*in1ammator2 dru. (G!&0D) can -eprescri-ed also to e"aluate
t%e response# & "iral or idiopat%ic form is often responsi"e
tosuc% empiric t%erap2# )or t%e mana.ement of recurrent in1ammator2
cases' t%e Hrst stepis considerin. t%e com-ination of aspirin or a
G!&0D plus colc%icine' ,%ilecorticosteroids at lo, to moderate
doses ma2 -e considered for speciHc indications (i#e#s2stemic
in1ammator2 diseases and prenanc2)' and in case of
intolerance'contraindications' or failure of aspirinIG!&0DV
ot%er t%erapies are -ased on less solide"idence: less to8ic and
less e8pensi"e dru.s (e#.# aKat%ioprine or met%otre8ate) s%ould26-e
preferred' tailorin. t%e t%erap2 for t%e indi"idual patient and t%e
p%2siciane8perience#0-uprofen is proposed as t%e fa"ourite Hrst
c%oice for empiric anti*in1ammator2t%erap2 of pericarditis' due to
rare side effects' fa"oura-le effect on t%e coronar2 1o,'and t%e
lar.e dose ran.e# Ho,e"er' ot%er approac%es %a"e -een pu-lis%ed'
and aspirin isused as Hrst fa"ourite c%oice in se"eral clinical
trials in t%e settin. of acute and recurrentpericarditis# )or
patients ,%o alread2 are ta5in. or need aspirin' suc% dru. is t%e
-estanti in1ammator2c%oice# 0nt%e settin.of post*m2ocardial
infarctionpericarditis'i-uprofen' ,%ic% increases t%e coronar2 1o,'
is t%e preferred a.ent of c%oice accordin.#&spirin %as -een
also successfull2 applied#10Ot%er nonsteroidal a.ents ma2 increase
t%e ris5 of t%innin. t%e infarction
Kone#Corticosteroidt%erap2can-eusedfor refractor2s2mptoms onl2' -ut
coulddela2m2ocardial infarction %ealin. (class 00a indication'
le"el of e"idence 7)# Post infarctionpericardial effusion U10 mm
ma2 -e associated ,it% %aemopericardium' and up to t,o*t%irds of
t%ese patients ma2 de"elop tamponadeIfree ,all rupture# 0n t%is
settin.' ur.entsur.ical treatment is life sa"in.# Ho,e"er' if t%e
immediate sur.er2 is not a"aila-le orcontraindicated'
pericardiocentesis' andintrapericardial
H-rin.lueinstillationcouldpro"ideanalternati"eimmediatetreatment#
0nt%esettin.ofautoreacti"epericardialeffusion'
.ro,in.e"idencesupportst%epossi-leuseofintrapericardial
t%erapiestoreduce side effects related to t%e oral use of
corticosteroids#10>%en a pericardial effusion -ecomes
s2mptomatic ,it%out e"idence of in1ammation
or,%enempiricanti*in1ammator2dru.s arenot successful' draina.eof
t%eeffusions%ould-econsidered#
Pericardiocentesis,it%prolon.edpericardial draina.etill90mEI2; % is
recommended to promote ad%erence of pericardial la2ers and pre"ent
furt%eraccumulationof1uid' alt%ou.%e"idencetosupport
t%isindicationis-asedoncasereports' retrospecti"e studies' and
e8pert opinion# 0f pericardiocentesis is not feasi-le orfails'
t%ecreationofasocalledpericardial
,indo,s%ould-econsideredeit%er-2con"entional %eart sur.er2 or
"ideoassisted t%oracoscop2# 7alloon pericardiotom2 is analternati"e
to sur.ical creation of a pericardial ,indo,' ,%ic% %as -een
s%o,nsuccessful especiall2int%esettin.of neoplasticpericardial
disease# 6%etec%ni+uein"ol"es insertin. a de1ated sin.le cat%eter
or dou-le -alloon cat%eters into t%epericardial space usin. a
su-8ip%oid approac% under 1uoroscopic or
ec%ocardio.rap%ic27.uidance# <%ou.% successful in pre"entin.
recurrence in F0@ of cases' stretc%in. oft%e pericardium is often
painful so appropriate anal.esia is recommended#&recommendation
to pericardiectom2 for fre+uent and %i.%l2 s2mptomatic
recurrencesresistant to medical treatment# Ot%er reported
indications include repeated recurrences,it%cardiactamponade'
ande"idenceofserioussteroidto8icit2#<%ou.%sur.icale8periencesarenotal,a2sconcordant'
pericardiectom2is.enerall2consideredasat%erapeutic option of
dou-tful efHcac2 in recurrent idiopat%ic pericarditis or
pericardialeffusionands%ould-econsideredonl2ine8* ceptional cases#
C%ronicpermanentconstrictionremains t%ema4or indicationfor
suc%inter"ention# Ho,e"er' incessantpericarditis' as distin.uis%ed
fromrecurrent intermittent pericarditis' ma2
respondfa"oura-l2tosur.ical remo"al' especiall2int%e presence of
recurrent pericardialeffusion# &n idiopat%ic c%ronic
pericardial effusion is deHned as a collection ofpericardial 1uid
t%at persists for 9 mont%s and %as no apparent causeV lar.e
effusions%a"e a ris5 of pro.ression to cardiac tamponade (up to one
t%ird' accordin. to a !panis%stud2)# On t%is -asis some aut%ors
%a"e ad"ocated t%e need for pericardiectom2 for suc%cases' ,%ene"er
a lar.e effusionrecurs after pericardiocentesis# !ince draina.e
isrelati"el2 safe and eas2 in some cases ,it% .uided
pericardiocentesis' draina.e %as -eenrecommended for lar.e su-acute
effusions' t%at do not respond to empiric t%erap2' andare sta-le
after se"eral ,ee5s (e#.# :F ,ee5s)' especiall2 ,%en t%ere are
si.ns of ri.%tsidedcollapse' inordertopre"ent
t%epossi-lepro.ressionoft%eeffusionto,ardstamponade follo,in.
additional e"ents (e#.# pericarditis' -leedin. follo,in.
c%esttrauma)#1228REFRENCES+, Natina# Heart F!ndatin - A!stra#ia and
the Cardiac Sciety -A!stra#ia and Ne. /ea#and0 Dia$nsis and
mana$ement - ac!te rhe!matic-e%er and rhe!matic heart disease in
A!stra#ia0 1223,1, Indian Pediatric0 Cnsens!s G!ide#ines n
Pediatric Ac!te Rhe!maticFe%er and Rhe!matic Heart Disease (r4in$
Gr!' On Pediatric Ac!teRhe!matic Fe%er and Cardi#$y Cha'ter O-
Indian Academy O- Pediatric,5#!me 67, 1228,9, :Rem;nyi0 Ni$e#
(i#sn0Andre.Steer0:eatriRis4Factrs0
PatientPr-i#esandCntem'rary*ana$ement,The Sciety Thracic S!r$en,
12+2,