The evaluation of carcinoembryonic antigen determination in the pericardial fluid in the diagnosis of the cause of pericarditis

Pericardial fluid CEA level was measured with radioimmunoassay in 19 patients with large pericardial effusion of unknown origin. In 11 patients malignancy was diagnosed. In all of these patients pericardial fluid CEA levels were above 7 ng/ml (mean value 52.6 +/- 42.6 ng/ml). In 8 patients the etiology of pericarditis was non-malignant. In all of them pericardial fluid CEA levels were below 7 ng/ml (mean value 2.2 +/- 1.6 ng/ml). In 9 patients with malignant pericarditis serum CEA levels were also determined: they were found to be lower than pericardial fluid CEA values in 6 patients. It was concluded that pericardial fluid CEA elevation is a reliable criteria of neoplastic pericardial involvement.     

Intrapericardial fibrinolysis: a useful treatment in the management of purulent pericarditis

Since the introduction of antibiotics into clinical practice, purulent pericarditis has become a rare disease. The major complication of the standard management for this condition is constrictive pericarditis. We report two cases of purulent pericarditis in which intrapericardial fibrinolysis was performed in order to minimize this complication. The first case was a 38-year-old man admitted to our intensive care unit (ICU) for management of constrictive pericarditis complicating purulent pericarditis diagnosed 17 days previously. The patient was treated with four intrapericardial injections of streptokinase (250,000 IU each). Fluid drainage and cardiac output were improved. No change in clotting parameters was noted. Pericardiectomy and esophagectomy were then performed for a diagnosis of esophageal neoplasm. The postoperative course was uneventful. The second case was a 16-year-old boy admitted with loss of consciousness due to cardiac tamponade. Percutaneous pericardiocentesis drained 900 ml of cloudy fluid. Two intrapericardial injections were performed (day 1 and day 5) without any complication. Pericardial drainage was withdrawn on day 13 and the patient was discharged from ICU on the same day. Six months later, there was no evidence of constrictive pericarditis. Intrapericardial fibrinolysis appears to be safe and effective when prescribed rapidly in the course of purulent pericarditis.     

Cardiac tamponade due to Nocardia asteroides

Pericarditis with hemodynamic compromise is a rare manifestation of infection with Nocardia asteroides. To our knowledge, only six cases have been reported previously. In contrast to other cases of pericardial disease due to Nocardia, culture of the pericardial fluid in our case was negative while culture of pericardial tissue led to the diagnosis. Surgical intervention and appropriate antibiotic therapy are essential in the treatment of Nocardia pericarditis.     

Comparison of PCR, culture, and histopathology for diagnosis of tuberculous pericarditis

Nucleic acid amplification techniques for the diagnosis of tuberculosis (TB) are rapidly being developed. Scant work, however, has focused on pericardial TB. Using cryopreserved specimens from a prior study of pericarditis, we compared PCR to culture and histopathology for the diagnosis of tuberculous pericarditis in 36 specimens of pericardial fluid and 19 specimens of pericardial tissue from 20 patients. Fluid and tissue were cultured on Lowenstein-Jensen and Middlebrook solid media and in BACTEC radiometric broth. Tissue specimens were stained with hematoxylin-eosin, Ziehl-Neelsen, auramine O, and Kinyoun stains and were examined for granuloma formation and acid-fast bacilli. PCR was performed with both fluid and tissue with IS6110-based primers specific for the Mycobacterium tuberculosis complex by published methods. Sixteen of the 20 patients had tuberculous pericarditis and 4 patients had other diagnoses. TB was correctly diagnosed by culture in 15 (93%) patients, by PCR in 13 (81%) patients, and by histology in 13 of 15 (87%) patients. PCR gave one false-positive result for a patient with Staphylococcus aureus pericarditis. Considering the individual specimens as the unit of analysis, M. tuberculosis was identified by culture in 30 of 43 specimens (70%) from patients with tuberculous pericarditis and by PCR in 14 of 28 specimens (50%) from patients with tuberculous pericarditis (P > 0.15). The sensitivity of PCR was higher with tissue specimens (12 of 15; 80%) than with fluid specimens (2 of 13; 15%; P = 0.002). In conclusion, the overall accuracy of PCR approached the results of conventional methods, although PCR was much faster. Therefore, PCR merits further development in this regard. The sensitivity of PCR with pericardial fluid was poor, and false-positive results with PCR remain a concern.     

Tuberculosis in circulation system

Tuberculous pericarditis develops either via hematogenous or lymphangeal spread, or directly from pulmonary lesions. Tuberculous pericarditis begins with fibrin deposits, granuloma formation, and the presence of live acid-fast bacilli. A pericardial effusion, which is serous but often contains some blood with a high level of protein. Recently, PCR technology has been employed to amplify M. Tuberculosis DNA from pericardial fluid. The elevation of ADA (> 45 U/l) is supportive of the diagnosis. Tuberculous pericarditis is detected clinically either in the effusive stage by nonspecific systemic syndrome or after the development of constrictive pericarditis. The short-course treatment of tuberculous pericarditis should consist of three-drug regimen, such as INH, RFP, PZA, SM, EB. The use of prednisolone is controversial. Tuberculous myocarditis is extremely rare because of low affinity between M. Tuberculosis and myocardium. Most cases of tuberculous pericarditis are clinically silent and diagnosed at autopsy.     

Characterization and stimuli for production of pericardial fluid atrial natriuretic peptide in dogs

Recently high immunoreactive atrial natriuretic peptide (ir-ANP) levels have been found in the pericardial fluid of patients undergoing cardiac surgery. The present study was designed to characterize pericardial fluid ANP in anesthetized dogs. Pericardial fluid ir-ANP levels were 3.4-fold higher than plasma levels and the molecular form, revealed by high performance liquid chromatography, was indistinguishable from ANP[99-126]. Elimination of [125I]ANP was 5-fold slower in the pericardial space than in plasma. Activity of the major ANP degrading enzyme, neutral endopeptidase (NEP, EC 3.4.24.11), was 15-times higher in the pericardial fluid than in plasma. Right atrial balloon distension and rapid right ventricular pacing induced maximally 2.3-fold and 1.5-fold increases of pericardial fluid ir-ANP, respectively. Pericardial fluid ir-ANP concentrations and right atrial pressure values showed significant correlation during the stimuli. Our present results show that high concentrations of ir-ANP can be found in the dog pericardial fluid even under unstimulated conditions. Slow elimination of ANP from the pericardial fluid compartment may contribute to the high peptide levels. However this slow elimination cannot be attributed to a lower NEP activity. High basal levels of ANP in the pericardial fluid could be further increased by atrial balloon stretch and rapid ventricular pacing. The increase of pericardial fluid ir-ANP appeared to be a stretch-dependent response. ANP released into the pericardial fluid may be involved in the regulation of cardiac function and coronary vascular tone.     

Reversal of intractable uremic pericarditis by triamcinolone hexacetonide

Of 74 patients undergoing long-term hemodialysis who were observed during a 21-month period, seven developed uremic pericarditis. Five of these patients developed intractable pericarditis, unresponsive to intensive dialysis and pericardiocentesis, and were treated with prolonged pericardial drainage (16 to 60 hours) by an indwelling polyethylene catheter and instillation of triamcinolone hexacetonide. Evidence of intractability was based on either the recurrence of cardiac tamponade after pericardiocentesis (two patients) or progression in the size of the pericardial effusion despite four weeks of intensive dialysis (three patients). These five patients recovered and subsequently were observed from 1 to 15 months with no evidence of recurrent pericarditis. This procedure may be an effective alternative to the surgical management of intractable uremic pericarditis, particularly in the patient at high risk for anesthesia and major surgery.     

Two cases of tuberculous constrictive pericarditis

Case 1 was a 79-year-old male suspected of tuberculous constrictive pericarditis. He was admitted to our hospital because of surgical treatment. His heart failure was NYHA IV. Culture of pleural effusion and pericardial effusion was negative. But ADA level in pericardial effusion was found to be increased. So tuberculosis was suspected. Cardiac catheterization date was compatible with constrictive pericarditis. Case 2 was a 73-year-old female. She was admitted because of heart failure (NYHA IV). As RVP wave indicated dip & platou at cardiac catheterization, she was diagnosed as constrictive pericarditis. ADA level in pleural effusion increased. So tuberculosis was suspected as etiology of constrictive pericarditis. In both cases, after pericardiectomy, heart failure improved to NYHA I. Results of pathological examination were tuberculous inflammation.     

Cerebral haemorrhage triggered by calcium antagonist

On the basis of our reported experience with colchicine for recurrent pericarditis, we administered colchicine to two patients with large pericardial effusions complicating idiopathic pericarditis. The first was a 26-year-old male who showed clinical deterioration following emergency pericardiocentesis and aspirin (3 g/day) for 10 days; the second was a 2-year-old girl who was unsuccessfully treated with aspirin (100 mg/kg/day) for 2 weeks, followed by corticosteroids for 7 months. Administration of colchicine (1 mg/day) instead of aspirin in the first case, and with a rapid tapering-off of the corticosteroids in the second case, led to complete regression of the pericardial effusion on echocardiography within 1 week and 1 month, respectively. Colchicine was discontinued after 1 month in the first patient and was continued for 6 months in the child. Neither has had a recurrence at 24 and 6 months of follow-up, respectively. No side effects of colchicine were observed. We conclude that colchicine may be effective in the treatment of large pericardial effusion when therapy with nonsteroidal anti-inflammatory drugs and/or corticosteroids fails.     

Pericarditis induced by high-dose cytosine arabinoside chemotherapy

Pericarditis is a rare side effect of chemotherapy. We report here the case of a patient treated with high-dose cytosine arabinoside (HD ara-c) who developed severe pericarditis. Interruption of HD ara-c and initiation of corticosteroid treatment were effective in resolving the pericardial effusion. This case illustrates this rare but potentially life-threatening cardiac complication of HD ara-c therapy as well as the beneficial effect of corticosteroid treatment.     

Potent HIV protease inhibitors incorporating high-affinity P2-ligands and (R)-(hydroxyethylamino)sulfonamide isostere

We performed percutaneous balloon pericardiotomy and pulmonary valvuloplasty in a woman affected with cardiac and pericardial involvement from a primary pulmonary adenocarcinoma. Pericardial window was indicated for a recurrent, symptomatic, pericardial effusion. Valvular stenosis was severe and related to metastatic infiltration of cardiac tissue. Open surgery was avoided and the procedures were completed in two steps under local anesthesia in less than 60 min. The patient had no recurrence of pulmonary stenosis or pericardial effusion at 7 months post treatment. Transcatheter techniques are successful in helping to manage malignant diseases with cardiac metastasis, particularly in critically-ill patients. It may become the preferred treatment for avoiding a more invasive procedure for patients with a limited life expectancy.     

Spontaneous cardiac tamponade due to sternotomy wire suture

The first case of spontaneous cardiac tamponade caused by wire suture for sternotomy closure is presented. The proper analysis of bloody pericardial fluid, including simultaneous aspirate and venous hematocrit, oxygen content, and coagulation studies, is emphasized. In addition, the causes of acute hemopericardium are reviewed. Spontaneous cardiac tamponade as a potential late complication of cardiac surgery should be considered in the postoperative patient who presents with pericarditis or a sudden change in cardiac status.     

Pericarditis during inflammatory bowel diseases. Extra-intestinal or iatrogenic complication?

Acute pericarditis is rarely associated with inflammatory bowel disease. In such cases, when usual aetiologies have been excluded, pericarditis can be considered to be either an extraintestinal manifestation of inflammatory bowel disease or due to an adverse drug effect. We report a case of acute pericarditis in a 17-year old patient with ulcerative colitis treated with mesalazine for 15 days. Mesalazine was discontinued with a prompt and spontaneous resolution of the symptoms. Extensive investigations revealed no known cause for his pericarditis. Eight days and 75 days after the diagnosis, a lymphoblastic transformation test in the presence of mesalazine was performed and was positive for concentration greater than or equal to 10 micrograms/mL; this test was negative in 3 control patients treated with mesalazine without adverse drug effect. This observation together with the rare documented cases allows to consider the possibility that pericarditis may be caused by an adverse drug reaction in these patients.     

Catheter lavage and drainage of pneumococcal pericarditis

An 88 year old woman with streptococcal pneumonia developed purulent pericarditis and cardiac tamponade despite treatment with antibiotics. Percutaneous pericardial drainage was effected with a 6 French pigtail catheter inserted via the subxyphoid approach. Catheter drainage was continued for 7 days in conjunction with systemic antibiotics. Catheter patency was maintained with antibiotic lavage. Immediate hemodynamic improvement followed the initial pericardial drainage. Fever, leukocytosis, and sepsis resolved during the course of therapy. The patient recovered fully from the closed space bacterial infection without additional surgical drainage. There has been no recurrence of streptococcal infection and no echocardiographic evidence of recurrent pericardial effusion after 3 months of follow-up. Indwelling catheter drainage combined with antibiotics may be an effective substitute for surgical drainage in the treatment of streptococcal pericarditis.     

Cytarabine-induced pericarditis

We report two cases of cytarabine (Ara-C) induced pericarditis. The first patient was a 61-year-old man with de novo acute myelogenous leukemia (AML) with trilineage myelodysplasia (M2). Fever and pericardial effusion developed after treatment with low-dose Ara-C and etoposide (VP16) during the patient's second leukemic relapse. The second patient was a 65-year-old man with myelodysplastic syndrome (MDS) transformed into AML (M2). He achieved a complete remission after treatment with low-dose Ara-C and VP16. However, during consolidation chemotherapy consisting of oral cytarabine ocfosfate and VP16, fever and pericardial effusion developed. In both cases, pericardiocentesis revealed exudative effusion with many neutrophils. Neither bacterial nor fungal infection was demonstrated. Chest symptoms and fever were resolved by methylprednisolone pulse therapy and pericardial drainage. Both patients were given a diagnosis of pericarditis caused by allergic reaction to Ara-C. We also report on 6 other patients with Ara-C syndrome who have been encountered by our hospital.     

Uremic pericarditis: a prospective echocardiographic and clinical study

During a 14 month period 59 male patients with chronic renal failure who were candidates for chronic hemodialysis (HD) were evaluated clinically and echocardiographically for pericarditis. All were evaluated prospectively prior to or at the initiation of HD. Definite pericarditis was present in 8, all of whom were severely uremic and required initiation of HD on a semiemergent basis rather than electively (i.e., preselected level of renal function). In 6 of these 8, pericardial effusion responded to dialysis alone, one required pericardiectomy because of hypotension complicating dialysis, and one expired during a right atriogram. Patients dialyzed on an elective basis were all free of pericarditis at the initiation of HD. Pericarditis arising some months after the initiation of HD was a less frequent problem. It is concluded that (a) the incidence of pericarditis in the uremic state is decreased by early initiation of HD before advanced uremic symptoms have developed; (b) pericarditis present at the initiation of HD usually but not always is resolved with the initiation of HD; (c) echocardiography is an important clinical and epidemiological toole to investigate pericarditis in uremic patient populations.     

Constrictive pericarditis after coronary artery bypass surgery as a cause of unexplained dyspnea: a report of five cases

Constrictive pericarditis after coronary artery bypass grafting (CABG) is rare and can present as unexplained dyspnea. We report five consecutive cases of post-CABG constrictive pericarditis seen within a period of 17 months at our institution. All patients presented with heart failure of unknown etiology within a period of 8-84 months after surgery. During the initial post-CABG period, two patients had developed postcardiotomy syndrome that was successfully treated with steroids. They were all assessed noninvasively and invasively. In all patients, the diagnosis of constriction was initially suspected clinically (symptoms, high jugular venous pressure with deep "X" and "Y" descents, pericardial knock). Echocardiography showed transmitral flow typical of constriction in all patients and hepatic venous flow in two. Two patients showed rapid left ventricular relaxation. In all patients, hemodynamic assessment showed diastolic equalization of pressures in all chambers, "W" shape waveform in right atrial pressure, and "dip and plateau" configuration in right and left ventricular pressure waveforms. Diagnosis was confirmed surgically in four patients who were subjected to pericardiectomy-pericardial stripping (three survived, one died). One patient refused surgery. We conclude that constrictive pericarditis, although rare, should be suspected in every case of unexplained dyspnea post CABG. It can appear early or late after surgery, and clinical examination plays an important role in its early recognition. It requires a full noninvasive and invasive assessment in case of clinical suspicion.     

European Consensus Statement on Neonatal Hearing Screening. Finalised at the European Consensus Development Conference on Neonatal Hearing Screening, 15-16 May 1998, Milan

Lyme disease is well known for affecting the myocardium in the form of carditis and dilated cardiomyopathy. Pericardial effusion associated with Lyme disease has not been described as yet. This article demonstrates a case of a female patient, 54 years of age, with Borrelia burgdorferi infection and associated pericardial effusion. Recurrent pericardiocenteses as well as conventional treatment of the condition were without success. Diagnosis of Borrelia infection and subsequent treatment with ceftriaxone led to permanent restitution of the pericardial effusion.     

Chylous cardiac tamponade in acute pancreatitis

A 47-year-old woman with acute necrotizing pancreatitis developed sudden cardiorespiratory arrest and needed resuscitation. A pericardial effusion was found, and 350 ml of a white nontransparent milky fluid was aspirated that contained 1020 mg triglycerides/100 ml. The diagnosis of chylous cardiac tamponade was made. Absence of amylase in the chylous effusion militates against the popular hypothesis that lymphatic transport of exocrine digestive enzymes from the inflamed pancreas produces the frequent intrathoracic serosal effusions in acute pancreatitis. The data of our patient rather suggest that these effusions result from the leakage of pancreatic inflammatory exudates through the diaphragm which, apparently, may even result in the loss of pericardial and adjacent thoracic lymph vessel integrity. Although pericardial tamponade is a rare complication, it should be considered if otherwise unexplained circulatory deterioration occurs in a patient with acute pancreatitis.     

Acute leukemia presenting as pericardial effusion--a case report

We report a patient with acute lymphoblastic leukemia, who presented with pericardial effusion. There was no haematologic evidence of leukemia at the time of presentation. The pericardial effusion resolved with chemotherapy. Although a common finding at autopsy, clinically evident pericardial effusion is rare in leukemia. It is also extremely rare for pericardial effusion to be the presenting feature or to antedate haematologic evidence of leukemia. Physician awareness is important to make a correct diagnosis.