Diagnostic Considerations

Children with suspected myocarditis or pericarditis should be sent to an emergency department, particularly as these conditions need to be differentiated for appropriate management.^{[2, 4]} Note that the potential for threat to life is much more likely in the setting of clinically apparent myocarditis than for pericarditis.^{[2, 4]}

Indications for pericardial drainage include hemodynamic instability or diagnostic uncertainty for the etiology of the pericardial effusion. Early identification of bacterial effusion is important because it requires antibiotic therapy and pericardial drainage. Any underlying collagen-vascular disease must be recognized.

Diseases associated with pericardial effusion and tamponade include the following:

Infectious pericarditis (fungal pericarditis)
Malignancy
Autoimmune disorders
Connective tissue diseases (see Mixed Connective Tissue Disease, Undifferentiated Connective-Tissue Disease)
End-stage renal disease (uremic pericarditis)
Chest trauma and post cardiac surgical injury (see Penetrating Chest Trauma, Blunt Chest Trauma)
Extravasation from central venous catheter
Rheumatic fever
Chylous effusions
Post pericardiotomy syndrome
Hypersensitivity to drugs/toxins
Hypothyroidism

See Infective Endocarditis for more detailed information on this topic.

Differential Diagnoses

Constrictive Pericarditis
Esophagitis
Neonatal Sepsis
Pediatric Bacterial Endocarditis
Pediatric Fungal Endocarditis
Pediatric Infective Pericarditis
Pediatric Malignant Pericardial Effusion
Pediatric Nonviral Myocarditis
Pediatric Pneumonia
Pediatric Rheumatic Heart Disease
Pediatric Viral Myocarditis
Pneumothorax Imaging
Postpericardiotomy Syndrome
Rheumatic Fever in Emergency Medicine
Systemic Lupus Erythematosus (SLE)
Thalassemia Imaging
Tuberculous Pericarditis

Workup

Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: a systematic review. JAMA. 2015 Oct 13. 314(14):1498-506. [QxMD MEDLINE Link].
O'Connor MJ. Imaging the itis: endocarditis, myocarditis, and pericarditis. Curr Opin Cardiol. 2019 Jan. 34 (1):57-64. [QxMD MEDLINE Link].
Perez-Brandao C, Trigo C, F Pinto F. Pericarditis - clinical presentation and characteristics of a pediatric population. Rev Port Cardiol. 2019 Feb. 38 (2):97-101. [QxMD MEDLINE Link]. [Full Text].
Tunuguntla H, Jeewa A, Denfield SW. Acute myocarditis and pericarditis in children. Pediatr Rev. 2019 Jan. 40 (1):14-25. [QxMD MEDLINE Link].
Dawar R, Ganjoo A, Imdadi F, Bhandari V. Multidrug resistant invasive nontyphoidal Salmonella isolated from and masquerading healed tubercular constrictive pericarditis and study of virulence markers. Cureus. 2017 Apr 26. 9(4):e1198. [QxMD MEDLINE Link].
Roubille F, Gahide G, Moore-Morris T, et al. Epstein Barr virus (EBV) and acute myopericarditis in an immunocompetent patient: first demonstrated case and discussion. Intern Med. 2008. 47(7):627-9. [QxMD MEDLINE Link].
Wu CT, Huang JL. Pericarditis with massive pericardial effusion in a cytomegalovirus-infected infant. Acta Cardiol. 2009 Oct. 64(5):669-71. [QxMD MEDLINE Link].
Tapparel C, L'Huillier AG, Rougemont AL, Beghetti M, Barazzone-Argiroffo C, Kaiser L. Pneumonia and pericarditis in a child with HRV-C infection: a case report. J Clin Virol. 2009 Jun. 45(2):157-60. [QxMD MEDLINE Link].
Natrajsetty HS, Vijayalakshmi IB, Narasimhan C, Manjunath CN. Purulent pericarditis with quadruple valve endocarditis. Am J Case Rep. 2015 Apr 23. 16:236-9. [QxMD MEDLINE Link].
Tani T, Okada Y, Kita T, Furukawa Y. Destructive acute infective endocarditis and purulent pericarditis. J Echocardiogr. 2013 Dec. 11(4):164-6. [QxMD MEDLINE Link].
Kashif M, Raiyani H, Niazi M, Gayathri K, Vakde T. Purulent pericarditis: an uncommon presentation of a common organism. Am J Case Rep. 2017 Apr 6. 18:355-60. [QxMD MEDLINE Link].
Azhar A. Successful management of fungal pericarditis and endocarditis in a neonate: A case report. J Saudi Heart Assoc. 2012 Jul. 24(3):195-9. [QxMD MEDLINE Link].
Ratnapalan S, Brown K, Benson L. Children presenting with acute pericarditis to the emergency department. Pediatr Emerg Care. 2011 Jul. 27(7):581-5. [QxMD MEDLINE Link].
Mann-Segal DD, Shanahan EA, Jones B, Ramasamy D. Purulent pericarditis: rediscovery of an old remedy. J Thorac Cardiovasc Surg. 1996 Feb. 111(2):487-8. [QxMD MEDLINE Link].
Moraes AN, Ferreira AG Jr, Ferreira SM. Left ventricular pseudoaneurysm complicating infective pericarditis. Heart. 1999 Sep. 82(3):393-4. [QxMD MEDLINE Link].
Desai M, Gandhi H, Mishra A. Post-infective pericarditis left ventricular pseudoaneurysm: a case report and review of literature. Cardiol Young. 2015 Feb. 25(2):358-61. [QxMD MEDLINE Link].
Meier D, Kirsch M, Qanadli SD, Muller O, Fishman D, Trana C. Case report of an unusual combination of purulent pericarditis and false aneurysm of the ascending aorta. J Cardiothorac Surg. 2018 Jan 29. 13(1):15. [QxMD MEDLINE Link].
Masood SA, Kiel E, Akingbola O, Green R, Hodges L, Petterway G. Cardiac tamponade and pleural effusion complicating varicella: a case report. Pediatr Emerg Care. 2008 Nov. 24(11):777-81. [QxMD MEDLINE Link].
Kobayashi D, Aggarwal S, Kheiwa A, Shah N. Myopericarditis in children: elevated troponin I level does not predict outcome. Pediatr Cardiol. 2012 Oct. 33(7):1040-5. [QxMD MEDLINE Link].
Ananthasubramaniam K, Farha A. Primary right atrial angiosarcoma mimicking acute pericarditis, pulmonary embolism, and tricuspid stenosis. Heart. 1999 May. 81(5):556-8. [QxMD MEDLINE Link]. [Full Text].
Habashy AG, Mittal A, Ravichandran N, Cherian G. The electrocardiogram in large pericardial effusion: the forgotten "P" wave and the influence of tamponade, size, etiology, and pericardial thickness on QRS voltage. Angiology. 2004 May-Jun. 55(3):303-7. [QxMD MEDLINE Link].
Bhardwaj R, Berzingi C, Miller C, et al. Differential diagnosis of acute pericarditis from normal variant early repolarization and left ventricular hypertrophy with early repolarization: an electrocardiographic study. Am J Med Sci. 2013 Jan. 345(1):28-32. [QxMD MEDLINE Link].
[Guideline] Adler Y, Charron P, Imazio M, et al, for the ESC Scientific Document Group. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015 Nov 7. 36 (42):2921-64. [QxMD MEDLINE Link]. [Full Text].
Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation. 2005 Sep 27. 112(13):2012-6. [QxMD MEDLINE Link].
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Media Gallery

Two-dimensional echocardiograph shows a large pericardial effusion.
M-mode echocardiograph shows moderate pericardial effusion.
Plain chest radiograph in a 2-year-old boy with viral pericarditis and massive pericardial effusion.
Left: Chest radiograph in a patient with bacterial pericarditis reveals cardiomegaly and left lower lobe infiltrate with marked increase in pulmonary vascular markings. Right: The same patient after placement of a pigtail pericardial catheter and pulmonary artery catheter.
Apical four-chamber view from a patient with bacterial pericarditis. The large pericardial effusion (EF) appears as an echo clear space in this view surrounding the right atrium (RA) and left ventricle (LV). The RA wall is collapsed, indicating tamponade. The longer the duration of RA inversion into systole correlates with increasing hemodynamic severity.
A 12-lead ECG from a patient with bacterial pericarditis demonstrating marked ST elevation in multiple leads.
This ECG shows markedly decreased QRS voltage and electrical alternans (especially in lead V1)

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Author

Poothirikovil Venugopalan, MBBS, MD, FRCPCH Consultant Pediatrician with Cardiology Expertise, Department of Child Health, Brighton and Sussex University Hospitals, NHS Trust; Honorary Senior Clinical Lecturer, Brighton and Sussex Medical School, UK

Poothirikovil Venugopalan, MBBS, MD, FRCPCH is a member of the following medical societies: British Congenital Cardiac Association, Paediatrician with Cardiology Expertise Special Interest Group, Royal College of Paediatrics and Child Health

Disclosure: Nothing to disclose.

Coauthor(s)

John Berger, MD Associate Professor, Department of Pediatrics, George Washington University School of Medicine, Director, Cardiac Intensive Care and Pulmonary Hypertension Program, Children's National Medical Center

John Berger, MD is a member of the following medical societies: American Academy of Pediatrics, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Hugh D Allen, MD Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine

Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, Western Society for Pediatric Research, American College of Cardiology, American Heart Association, American Pediatric Society

Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD Executive Director of The Heart Center, Interim Division Chief of Pediatric Cardiology, Lurie Childrens Hospital; Professor, Department of Pediatrics, Northwestern University, The Feinberg School of Medicine

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Additional Contributors

Ira H Gessner, MD Professor Emeritus, Pediatric Cardiology, University of Florida College of Medicine

Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Sections Pediatric Infective Pericarditis
Overview
Presentation
DDx
Workup
Treatment
Medication
Media Gallery
References

Pediatric Infective Pericarditis Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

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