COVID-19-associated pericarditis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Reddy Vadiyala, M.B.B.S.[2]

Synonyms and keywords: Novel coronavirus, COVID-19, Wuhan Coronavirus, Coronavirus Disease-19, Coronavirus Disease 2019, SARS-CoV-2, COVID-19, COVID-19, 2019-nCoV, 2019 novel coronavirus, Cardiovascular finding in COVID-19, Pericardial injury in COVID-19, Pericarditis, Pericarditis in COVID-19, COVID-19-associated Pericarditis, SARS-CoV2-associated Pericarditis, Myocardial injury in COVID-19, COVID-19 pericarditis

Overview

COVID-19 is caused by the novel coronavirus, also known as SARS-CoV-2. It mainly affects the lungs, causing severe acute respiratory syndrome. It invades through the Angiotensin-converting enzyme 2 (ACE2) receptors present abundantly not only in the lungs but also in the heart, kidneys, intestine, brain, skin thus causing multiorgan dysfunction. Studies have demonstrated that COVID-19 interacts with the cardiovascular system, thereby causing myocardial injury and dysfunction as well as increasing morbidity among patients with underlying cardiovascular conditions. Pericarditis in COVID-19 is a rare complication.

Historical Perspective

• The novel coronavirus, SARS-CoV-2, is identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in late December 2019. SARS-CoV-2 has rapidly spread across China and in other countries, raising major global concerns. This novel coronavirus, SARS-CoV-2, was named the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) for it similarity severe acute respiratory syndrome related coronaviruses such as SARS-CoV, which caused acute respiratory distress syndrome (ARDS) in 2002–2003.
• On January 30, 2020,the World Health Organization(WHO) declared the outbreak as a Public Health Emergency of International Concern.
• On March 12, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic.

Classification

• There is no established system for the classification of the pericarditis seen in COVID-19.
• For more information regarding general classification, see the pericarditis classification.

Pathophysiology

• Viral infections are a common cause of pericarditis. It is hypothesized that viruses cause pericardial inflammation via direct cytotoxic effects or via immune-mediated mechanisms.
• The exact mechanism of COVID-19 induced pericarditis is not yet well known.
• Probable mechanisms of COVID-19-associated pericarditis from the limited cases reported:
  • Direct invasion of the virus
  • Cytokine storm and systemic hyperinflammatory response: This might be leading to pericarditis and subsequent pericardial effusion in certain patients

Causes

Pericarditis in COVID-19 is caused by:

• Direct invasion by SARS-CoV-2.
• Pro-inflammatory cytokine storm

Differentiating [COVID-19-associated pericarditis] from other Diseases

Pericarditis in COVID-19 must be differentiated from other diseases that cause chest pain, dyspnea such as:

• Myocarditis
• Pleural effusion
• Pulmonary embolism
• Heart failure

For general information on the differential diagnosis of pericarditis, refer to Differentiating Pericarditis from other Diseases

Epidemiology and Demographics

• Pericarditis is a rare manifestation of COVID-19.
• There is currently no available data on the incidence of pericarditis in COVID-19 patients.
• Very few case reports of pericarditis in COVID-19 patients.

Age

• There is no data on age predilection to pericarditis in COVID-19.

Gender

• There is no data on gender predilection to pericarditis in COVID-19.

Race

• There is no data on racial predilection to pericarditis in COVID-19.

Natural History, Complications and Prognosis

Natural History

• Pericarditis is inflammation of the pericardium.
• There can be an accompanying accumulation of either serous or fibrinous fluid leading to the development of pericardial effusion and cardiac tamponade. *The underlying myocardium may or may not be inflamed as well. If the myocardium is involved in the inflammatory process, it is called myopericarditis, and the CK and troponin levels may be elevated. Subsequent scarring of the pericardium may lead to constrictive pericarditis.

Complications

Common complications include:

• Pericardial Effusion
• Pericardial Tamponade
• Constrictive Pericarditis

Prognosis

There is no sufficient data on prognosis of COVID-19-associated pericarditis.

Diagnosis

Symptoms

• Symptoms of pericarditis in COVID-19 may include the following:

• Fever
• Chest pain
• Dyspnea
• Fatigue

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

There are no specific laboratory findings associated with COVID-19-associated pericarditis.

Electrocardiogram

• ST-elevation and PR depression are seen in pericarditis but it is not specific in COVID-19-related pericarditis.

Imaging

• On imaging by echocardiography and CT chest, the reported cases showed pericardial effusion.
• In two of the reported cases, late gadolinium sequences of CMR done to rule out myocarditis also showed extensive enhancement of the walls of the heart and the pericardium.

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].