COVID-19-associated pericarditis

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Main article: COVID-19

For COVID-19 frequently asked inpatient questions, click here
For COVID-19 frequently asked outpatient questions, click here
For COVID-19 patient information, click here

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 caused by the novel coronavirus, also known as SARS-CoV-2 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. Very few cases of COVID-19-associated pericarditis have been reported. Reports on large pericardial effusion and cardiac tamponade are rare in COVID-19.

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 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 general classification of pericarditis, click here.

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 are:
  • 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 likely caused by:

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

Differentiating COVID-19-associated pericarditis from other diseases

• For further information about the differential diagnosis, click here.
• For further information about the differential diagnosis of COVID-19, click here.

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.
• There are 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.
• The number of cases in females is more than males among the few cases reported.

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

• Prognosis is generally good. However, the presence of large pericardial effusion, tamponade, myopericarditis, high CRP, NO response to colchicine make prognosis worse.

Diagnosis

In the suspicion of acute pericarditis, obtaining an ECG, blood test sample of inflammatory and myocardial injury parameters and transthotacic echocardiography are recommended.

Symptoms

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

• Fever
• Chest pain
• Dyspnea
• Cough
• Fatigue
• Malaise

Physical Examination

• Physical examination may be remarkable for:

• Fever
• Pericardial friction rub
• Tachycardia, hypotension and distant heart sounds seen in cardiac tamponade

Laboratory Findings

Inflammatory biomarkers

• Non-specific markers of inflammation are commonly elevated in pericarditis. These include:
  • Leukocyte count
  • C-reactive protein (CRP)
  • Erythrocyte Sedimentation Rate (ESR)

• Elevated inflammatory markers, specifically WBC count and CRP was seen in COVID-19-associated pericarditis cases.

Cardiac biomarkers

• In the presence of concomitant myocarditis and pericarditis (myopericarditis), serum biomarkers of myocardial injury, are elevated. These include:
  • Creatine Kinase (CK)
  • Cardiac troponin I or T
  • Serum LDH

• Elevated cardiac markers was seen in COVID-19-associated pericarditis cases.

Electrocardiogram

• Electrocardiogram (ECG) findings see in the reported cases of COVID-19-associated pericarditis include:
  • ST elevation and PR depression are seen; but these changes are not specific to COVID-19 pericarditis.
  • Non-specific ST changes.
  • T wave inversion in the inferior leads (II, III and aVF).

• For ECG changes in pericarditis in general, click here.

Imaging

Chest X-ray

• Chest X-ray is usually within normal limits in acute pericarditis.
• Chest x-ray demonstrated an enlarged cardiac silhouette in patients with COVID-19 complicated by cardiac tamponade.

• For Chest X-ray findings in pericarditis, click here.

Echocardiography

• Echocardiography is the first-line test in the diagnosis of pericarditis and its complications.
• On imaging by echocardiography in the reported cases of COVID-19-associated pericarditis, findings included:
  • Small to moderate pericardial effusion.
  • In the cases complicated by cardiac tamponade, findings included:
    • Large pericardial effusion
    • Right ventricular diastolic collapse
    • Increased respiratory variation in peak E-wave mitral inflow velocity
    • Dilated inferior vena cava

For echocardiography findings in pericarditis in general, click here.

CT scan

• On CT chest, the reported cases showed pericardial effusion.

Cardiac magnetic resonance

• In two of the reported cases, late gadolinium sequences of cardiac magnetic resonance (CMR) done to rule out myocarditis also showed extensive enhancement of the walls of the heart and the pericardium.

Pericardial fluid analysis

• In the reported cases of cardiac tamponade in COVID-19 patients, pericardial fluid analysis from emergency pericardiocentesis showed:
  • Largely exudative effusion
  • High polymorphonuclear cell count
  • High protein and LDH levels

• Other work-up included:
  • Fluid cytology for malignant cells - negative
  • Gram stain, Acid-fast stain - negative
  • Bacterial, mycobacterial and fungal cultures - negative
  • Serum auto-immune work-up - negative

• Since there are no established laboratory parameters to help distinguish COVID-19-related pericardial effusion from other etiologies, complete biochemical, bacteriological and cytological analysis of pericardial fluid is suggested to rule out other etiologies of pericardial effusion.

Treatment

Medical Therapy

• The efficacy of colchicine in acute pericarditis is related to reducing chest pain, decreaseing the leukocyte mobility and phagocytosis observing in inflammatory process.

• NSAIDs and high-dose aspirin and are the mainstay of therapy for acute pericarditis.
• Colchicine is recommended as first-line therapy for acute pericarditis as an adjunctive to NSAIDs/Aspririn
• Corticosteroids are reserved for cases with a contraindication or failure of first-line therapies.
• With early anecdotal reports linking NSAIDs and corticosteroids with a worsening clinical condition in patients with COVID-19, there have been recommendations against the use of these agents. However, according to the recommendations from the US Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), NSAIDs can be used when clinically indicated in COVID-19 patients.
• There is no literature and existing data to provide definite evidence for or against the use of high- or low-dose aspirin when clinically indicated in patients with COVID-19.
• In one of the reported cases of COVID-19-associated pericarditis and cardiac tamponade, colchicine was well tolerated as monotherapy.
• In another case of COVID-19 and cardiac tamponade, the combination of corticosteroids and colchicine was well tolerated and successful.
• Response to treatment can be monitored with serial transthoracic echocardiogram (TTE).

Surgery

• In all the reported cases of COVID-19 with large effusions and cardiac tamponade, pericardiocentesis showed improvement in symptoms.
• Response to treatment can be monitored with serial transthoracic echocardiogram (TTE).

Primary Prevention

• There are no established measures for the primary prevention of COVID-19-associated pericarditis.
• For primary preventive measures of [COVID-19], click here.

Secondary Prevention

• There are no established measures for the secondary prevention of COVID-19-associated pericarditis.
• For secondary preventive measures of COVID-19, click here.