Differentials
Common
Malignancy
History
history of lung cancer, breast cancer, haematological malignancies, less frequently primary pericardial neoplasms (e.g., mesothelioma), previous pericardial effusion
Exam
lymphadenopathy, cachexia, pericardial rub, distant heart sounds
1st investigation
- echocardiography:
pericardial effusion; clear or organised
More - chest x-ray:
normal or water-bottle-shaped enlarged cardiac silhouette; may show lung lesion or mediastinal lymphadenopathy
More - ECG:
sinus tachycardia, low QRS voltage, electrical alternans in tamponade
- FBC:
normal white blood cell count
- CRP:
usually normal
- erythrocyte sedimentation rate:
usually normal
Viral pericarditis
History
acute or recent infection, chest discomfort that varies with a change in position
Exam
pleuritic pain, pericardial rub, a low-grade temperature <38°C (<100°F), and specific viral-related findings such as a rash or pharyngeal exudate
1st investigation
- echocardiography:
pericardial effusion; rarely large enough to cause tamponade
- ECG:
diffuse ST-segment elevation and PR depression
More - FBC:
neutrophilia, elevated total white blood cell count
- CRP:
usually elevated
- erythrocyte sedimentation rate:
usually elevated
- serum troponin:
mildly elevated
More - chest x-ray:
normal or water-bottle-shaped enlarged cardiac silhouette
More
Other investigations
- blood cultures:
causative organism
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Iatrogenic
History
post-cardiac surgery or cardiac intervention, malaise, chest pain, dyspnoea; any change in postoperative clinical status should prompt consideration of an effusion
Exam
chest pain, dyspnoea, hypotension, tachycardia, elevated jugular venous pressure, pulsus paradoxus, diminished heart sounds in tamponade
1st investigation
- echocardiography:
pericardial effusion; more likely to be loculated, haemorrhagic, organised
- ECG:
sinus tachycardia, low QRS voltage, electrical alternans in tamponade
- chest x-ray:
normal or water-bottle-shaped enlarged cardiac silhouette
More
Other investigations
Idiopathic
History
chest pain or discomfort that varies with change of position, low-grade fever, cough, dyspnoea
Exam
fever, pericardial rub, distant heart sounds
1st investigation
- echocardiography:
pericardial effusion; rarely large enough to cause tamponade, course of pericardial effusion usually self-limiting and benign
- ECG:
diffuse ST-segment elevation and PR depression
- FBC:
usually normal
- CRP:
usually normal
- erythrocyte sedimentation rate:
usually normal
- serum troponin:
mildly elevated
More - chest x-ray:
normal or water-bottle-shaped enlarged cardiac silhouette
More
Other investigations
Congestive heart failure
History
history of hypertension, coronary atherosclerotic heart disease, valvular disease, or cardiomyopathy; shortness of breath, decreased exercise tolerance, orthopnoea, and paroxysmal nocturnal dyspnoea
Exam
elevated jugular venous pressure, pulmonary crackles, peripheral oedema, palpable pulsus alternans, S3 gallop
1st investigation
- echocardiography:
systolic heart failure: depressed and dilated left and/or right ventricle with low ejection fraction; diastolic heart failure: left ventricular ejection fraction normal but left ventricular hypertrophy and abnormal diastolic filling patterns
- chest x-ray:
evidence of pulmonary oedema, pleural effusion, or cardiomegaly
- ECG:
sinus tachycardia, low QRS voltage; may show evidence of underlying coronary artery disease, left ventricular hypertrophy, or atrial enlargement; may be conduction abnormalities and abnormal QRS duration
Other investigations
Uraemia
History
known end-stage renal failure, dialysis; pleuritic thoracic pain consistent with acute pericarditis; associated symptoms of uraemia such as nausea, vomiting, mental status changes, and uraemic frost may be present
Exam
dyspnoea, signs of fluid overload, a pericardial friction rub indicates pericardial inflammation
1st investigation
Other investigations
Uncommon
Bacterial pericarditis
History
history of concomitant infection, e.g., pleural empyema/adjacent pneumonia/bacteraemia; history of direct cardiac trauma, immunosuppression, chronic disease, and alcoholism; high-grade fever; absence of chest pain
Exam
toxic appearance with high fever, tachypnoea, tachycardia, pericardial friction rub
1st investigation
- echocardiography:
pericardial effusion, partly or fully organised
- blood cultures:
positive
More - ECG:
diffuse ST-segment elevation and PR depression
More - FBC:
neutrophilia, elevated total white blood cell count
- CRP:
elevated
- erythrocyte sedimentation rate:
elevated
- serum troponin:
mildly elevated
More - chest x-ray:
normal or water-bottle-shaped enlarged cardiac silhouette
More
Other investigations
- pericardial fluid: culture and Gram stain:
positive
More
Tuberculous pericarditis
History
history of tuberculosis, patient from high-incidence country, HIV infection; subacute onset in conjunction with constitutional complaints including fever, cough, dyspnoea, night sweats, weight loss, and fatigue
Exam
distant heart sounds, cardiac dullness, elevated neck veins, hepatomegaly, pericardial knock
1st investigation
- echocardiography:
pericardial effusion
- chest x-ray:
pulmonary tuberculosis; may show cardiomegaly
More - ECG:
sinus tachycardia, low QRS voltage, electrical alternans if there is cardiac tamponade
Other investigations
Fungal pericarditis
History
history of chronic disease or suppressed immune system; endemic area for Histoplasma capsulatum and Coccidioides immitis; fever
Exam
may be normal or reveal pericardial friction rub, distant heart sounds; there are no specific signs suggestive of a fungal aetiology
1st investigation
- blood culture:
positive
More - echocardiography:
pericardial effusion
- ECG:
sinus tachycardia, low QRS voltage, electrical alternans if there is cardiac tamponade
Other investigations
- pericardial fluid culture:
positive
More
Chagas disease
History
history of exposure to Triatoma species, blood transfusion, organ transplantation, immunosuppression, health care or laboratory occupations, travel to or residence in endemic areas in Latin America, ingestion of contaminated food or drink; symptoms of myocarditis: palpitations, syncope or presyncope
Exam
prolonged fever (7 to 30 days) with nocturnal elevation, hepatosplenomegaly, lymphadenopathy, tachycardia
1st investigation
- echocardiography:
pericardial effusion
- FBC:
leukopenia or leukocytosis with a left shift and lymphocytosis; hypochromic anaemia; low platelets
More - ECG:
T wave alteration, prolonged PR interval, sinus tachycardia, low QRS voltage
- chest x-ray:
enlargement of cardiac area, pleural effusion
- microscopy of fresh blood or thick blood smear:
visualisation of trypomastigotes
Systemic lupus erythematosus
History
fatigue, arthralgia, malar rash, oral ulcers, and synovitis
Exam
malar rash, oral ulcers, arthritis, photosensitivity rash, discoid rash, and seizures may be present
1st investigation
Post-myocardial infarction syndrome (Dressler's phenomenon)
History
recent myocardial infarction
Exam
chest pain, dyspnoea, hypotension, tachycardia, elevated jugular venous pressure, pulsus paradoxus and diminished heart sounds in tamponade
1st investigation
- echocardiography:
pericardial effusion; cardiac tamponade is associated with left ventricular free wall rupture
- ECG:
sinus tachycardia, low QRS voltage, electrical alternans in tamponade
- chest x-ray:
normal or water-bottle-shaped enlarged cardiac silhouette; may show lung lesion or mediastinal lymphadenopathy
More
Other investigations
Drug-induced
History
treatment with hydralazine, procainamide, isoniazid, or certain antineoplastic drugs such as anthracyclines, cyclophosphamide, or immune checkpoint inhibitors
Exam
may be normal or reveal pericardial friction rub, distant heart sounds
1st investigation
Other investigations
- serum antihistone antibodies:
positive antihistone antibody
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Cardiac amyloidosis
History
history of known amyloid, multiple myeloma, monoclonal gammopathy, or chronic illness such as rheumatoid arthritis; easy bruising, fatigue, and weight loss
Exam
signs of congestive heart failure: elevated jugular venous pressure, pulmonary crackles, peripheral oedema, palpable pulsus alternans, S3 gallop, hepatomegaly
1st investigation
- echocardiography:
pericardial effusion; left ventricular hypertrophy ≥12 nm; reduced tissue Doppler s', e', and a' wave velocities (<5 cm/s); decreased global longitudinal left ventricular strain
More - ECG:
low-voltage ECG with a pseudo-infarct pattern
- chest x-ray:
normal or water-bottle-shaped enlarged cardiac silhouette; may show lung lesion or mediastinal lymphadenopathy
More
Other investigations
- serum and urine protein electrophoresis with immunofixation:
monoclonal immunoglobulin light chain spike
More - bone scan:
Grade 2 or 3 cardiac uptake of radiotracer in 99mTc-pyrophosphate (PYP), 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) or 99mTc-hydroxymethylene diphosphonate (HMDP) scintigraphy
More - cardiac magnetic resonance:
diffuse subendocardial or transmural late gadolinium enhancement, abnormal gadolinium kinetics, extracellular volume ≥0.40% (strongly supportive, but not essential/diagnostic)
- endomyocardial biopsy:
amyloid on Congo red stain
More - abdominal fat biopsy:
birefringent green on Congo red stain
More
Hypothyroidism
History
history of hypothyroidism, thyroid surgery, lethargy, constipation, cold intolerance
Exam
evidence of thyroid surgery, myxoedematous skin changes, bradycardia, diminished tendon reflexes
1st investigation
Other investigations
Ovarian hyperstimulation syndrome
History
history of ovarian stimulation with injectable gonadotrophins; chest pain, dyspnoea
Exam
muffled heart sounds, pericardial friction rub
1st investigation
- echocardiography:
pericardial effusion
- chest x-ray:
normal or water-bottle-shaped enlarged cardiac silhouette; may show lung lesion or mediastinal lymphadenopathy
More - ECG:
sinus tachycardia, low QRS voltage, electrical alternans in tamponade
Other investigations
Aortic dissection
History
tearing chest pain radiating to the back with sudden onset, stroke symptoms due to accompanying carotid artery dissection; history of aortic root dilation, connective tissue disease such as Marfan or Loeys-Dietz syndrome
Exam
blowing diastolic murmur, pulse differential between right and left arms; hypotension, tachycardia, elevated jugular venous pressure, pulsus paradoxus and diminished heart sounds in tamponade
1st investigation
Other investigations
- trans-oesophageal echocardiogram:
aortic dissection, intramural haematoma, pericardial effusion
Trauma
History
gunshot, stab wounds, or blunt trauma to the thorax
Exam
gunshot entrance wounds, stab wounds, hypotension often without elevated neck veins, or pulsus paradoxus
1st investigation
- echocardiography:
pericardial fluid
More - ECG:
sinus tachycardia, low QRS voltage, electrical alternans in tamponade
- chest x-ray:
widened mediastinum
Other investigations
- CT chest:
findings of direct penetrating or indirect injury to the heart
Radiation exposure
History
history of chest radiation
Exam
fever, chest pain, and pericardial rub in acute pericarditis during or after radiation, dyspnoea, hypotension, tachycardia, elevated jugular venous pressure, pulsus paradoxus and diminished heart sounds in tamponade
1st investigation
Other investigations
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