The pericardium is a 2-layered sac that contains the heart and
the proximal parts of the great vessels. The outer surface of the
sac is termed the parietal pericardium and is lined
by mesothelial cells. The inferior part of the sac is attached to
the diaphragm. The inner layer of the sac, also lined by mesothelial
cells, is attached to the cardiac surface and is known as the visceral
pericardium. A small amount of fluid fills the cavity between
the pericardial layers and acts as a lubricant so that the heart
can move within the sac. The parietal pericardium has blood and
lymphatic vessels. Disorders that affect the pericardium may be primary
or secondary to disease elsewhere in the body, including the heart
Whatever the cause, there are only 3 manifestations: acute or
chronic inflammation of the pericardial sac in response to injury
or accumulation of fluid between the 2 layers—a pericardial
effusion with or without a tamponade.
Acute pericarditis has many causes (see Table
491-1). No matter what the cause, the presentation is similar.
Table 491-1 Etiologya of
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Table 491-1 Etiologya of
|A. Idiopathic, presumed viral|
|B. Acute infections:|
|(1) Viral-coxsackie A and B, echovirus,
adenovirus, mumps virus, influenza virus, varicella zoster and vaccinia
viruses, Epstein-Barr virus, infectious mononucleosis, psittacosis-lymphogranuloma
venereum group, cytomegalovirus, rubella, herpes simplex, human
|(2) Bacterial-staphylococci, pneumococci,Haemophilus
influenzae, meningococci, streptococci, Salmonella,
mycobacteria with HIV infection virus|
|(4) Protozoa—amebae, toxoplasmosis|
|(5) Rickettsia—Coxiella burnetii|
|C. Physical causes:|
|(1) Hemopericardium and pericarditis after chest
trauma or cardiac surgery|
|(2) Serous or serosanguineous effusions
after cardiac trauma, cardiac surgery, or myocardial infarctions;
all may result from autoimmune mechanisms|
|(3) Perforation of right atrium by indwelling lines,
even soft silastic catheters|
|(4) Chest well radiation|
|D. Chronic infections:|
|(1) Tuberculosis, actinomycosis,
|(2) Fungi—histoplasmosis, coccidiomycosis, Candida spp,
|(3) Hydatid disease|
|E. Associated with anasarca in congestive heart failure,
nephrosis, or cirrhosis of the liver|
|F. Vasculitis syndromes, especially systemic lupus erythematosus,
rheumatoid arthritis, and rheumatic fever, but also scleroderma, polyarteritis,
Wegener granulomatosis, Behçet syndrome, Reiter syndrome,
|G. Metabolic disorders—uremia, myxedema, gout|
|I. Congenital heart disease, cardiomyopathy|
|J. Benign and malignant cavity|
|K. Drugs—hydralazine, procainamide, phenytoin, isoniazid,
phenylbutazone, methysergide, penicillin, anticoagulants, practolol,
|L. Certain anemias—sickle cell disease, thalassemia,
congenital aplastic anemia|
|M. Miscellaneous—dissecting aneurysm, acute, pancreatitis,
sarcoidosis, multiple myeloma, amyloidosis, Kawasaki syndrome, ulcerative
1. Chest pain is usually precordial and often referred
to the neck, shoulder, or epigastrium. The pain is sharp or burning
and is usually made better by sitting up and leaning forward. It
is made worse by taking in a deep breath because inspiration lowers
the diaphragm, pulls the pericardial sac down, and narrows it, thereby ...
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