Pericarditis
Dr. M Awais Niaz
Assistant Professor
Pathology department
Learning objectives
Define pericarditis
Enumerate causes of pericarditis
Enlist causes of each type of pericarditis
Describe morphology and pathogenesis of each
Pericardium (morphology)
Visceral layer
Parietal layer
Pericardial cavity with
pericardial fluid
The pericardial cavity
contains at most 30 to
50 mL of clear, serous
fluid
Pericardial diseases
Fluid accumulation…. Pericardial effusion
Inflammation….. Pericarditis
Fibrous constriction…Healed/chronic pericarditis
Pericardial effusion
Type of effusion Serous
Fibrinous
Hemorrhagic
Purulent
Caseous
Chylous
Slow collection over long period is well tolerated
Rapid collection results in
Cardiac tamponade
Pericarditis
Pericarditis …………Inflammation of pericardium
A. Acute Serous
Fibrinous/serofibrinous
Purulent/suppurative
Hemorrhagic
Caseous
B. Chronic Adhesive pericarditis
Adhesive mediastinopercarditis
Constrictive pericarditis
Causes of pericarditis
Infectious agents
viruses (coxsackievirus A and B, and hepatitis
Immunologically mediated viruses)
pyogenic bacteria (Pneumococci,
Rheumatic fever streptococci,staphylococci, Neisseria, Legionella)
Systemic lupus erythematosis M. tuberculosis
Post cardiotomy fungi (Fungal - Histoplasmosis, coccidioido-
mycosis, Candida)
scleroderma parasites
drug hypersensitivity reaction Miscellaneous
myocardial infarction (Dressler syndrome)
uremia
myxedema
following cardiac surgery
neoplasia lung ,breast,leukemia/lymphoma,
malignant melanoma, mesothelioma)
radiation
trauma
Aortic dissection
Pericarditis
Clinical features:
• sudden onset of sharp chest pain. The pain may also
be felt in the shoulders, neck, or back. It is typically
better sitting up and worse when lying down or
breathing deeply.
• Other symptoms may include fever, weakness,
palpitations, and shortness of breath
• pericardial friction rub on auscultation
• ST segment elevation on ECG
1. Serous pericarditis
Causes
1. Non infectious inflammatory disease
(Rheumatic Fever, SLE, scleroderma,
tumors, uremia)
2. Infection in contiguous organ
3. Infection in non-contiguous organ
4. Myopericarditis
5. hypoalbuminemia
6. congestive heart failure
Type of
effusion
Serous effusion ,
clear fluid may
contain few
lymphocytes
Outcome
Complete
resolution occurs
Organization to
fibrous adhesion is
very rare
2. Fibrinous/ serofibrinous pericardits
Causes:
Rheumatic Fever, SLE
acute MI
uremia
radiation
trauma
routine cardiac surgery
Fibrinous/serofibrinous pericardits
. Most frequent type
. Fluid is serous with fibrinous exudate
bread & butter pericarditis
Fibrinous/serofibrinous pericardits
Morphology:
• The epicardial surface
of the heart shows a
shaggy fibrinous
exudate making the
surface finely irregular.
• This appearance has
often been called a
"bread and butter"
pericarditis.
MICROSCOPY:
Strands of pink
fibrin extending
outward. There is
underlying
inflammation in
the pericardial
. layer
Type of
Effusion
Fluid is yellow to
brown, turbid,
contains leukocytes,
RBCs, fibrin
Outcome
. Fibrin can lyse with
MICROSCOPY: Strands of pink
resolution of exudate
fibrin extending outward. There is
. Fibrin can be
organized underlying inflammation in the
. pericardial layer
3. Suppurative/ Purulent pericarditis
It is an active infection caused by microbial
invasion of pericardial space.
Source can be
1. Direct extension from neighboring infection
(empyema, lobar pneumonia, mediastinal
infections)
2. Seeding from blood
3. Lymphatic extension
4. Direct introduction during cardiac surgery
3. Suppurative/ Purulent pericarditis
• Type of effusion: Exudative pericardial fluid…
thin, cloudy to frank pus… 400-500 ml
• Serosa is coated with exudate
• Causative organisms:
o Staphylococcus aureus
o streptococcus pneumoniae
o Streptococcus viridans
o H. influenzae
Gross
examination
yellowish exudate
(arrows) that has
pooled in the lower
pericardial sac
(asterisks) that has *
been opened here *
3. Suppurative/ Purulent pericarditis
• Outcome:
– Mediastinopericarditis
– Complete resolution… very rare
– Constrictive pericarditis… due to
intense inflammation and scarring
4. Hemorrhagic pericarditis
Causes
• Tuberculosis (80 percent of cases)
• Neoplastic involvement of pericardium
• Bleeding disorders
• Bacterial infections
• Cardiac surgery
Type of
effusion
. Fluid is blood+
fibrinous or blood+
suppurative exudate
. Neoplastic cells… If
neoplasia is cause
Outcome
. Resolution with lysis
of fibrin or can
become organized hemorrhagic pericarditis
demonstrates a roughened and
red appearance
5. Caseous pericarditis
Causes:
. until proven otherwise it is TUBERCULOUS
. Fungal is rare
Pericardium is involved by direct extension
Outcome:
fibrocalcific, chronic constrictive pericarditis
B. Chronic/healed pericarditis
Organization can form
plaque like fibrous thickening of serosal
membrane OR
thin, delicate adhesions
Adhesive pericarditis
mesh like stringy adhesions between parietal
and visceral layer of pericardium that obliterate
the sac but do not impair cardiac function
Adhesive mediastinopericarditis
causes: infections
cardiac surgery
mediastinal radiation
Pericardial sac is obliterated + parietal layer adheres to
surrounding , with systole the heart pulls against parietal
pericardium & surrounding structures
Results in :
Cardiac hypertrophy and dilatation
Constrictive pericarditis
heart encased in dense, fibrous, fibrocalcific scar
decrease diastolic expansion
decrease cardiac output
Constrictive pericarditis
•Heart cannot dilate because of enclosing scar
• Decrease output at rest
•Cannot increase output when demand
increases
•Classic Beck triad of pericardial tamponade:
Hypotension, muffled heart sounds, jugular
venous distention
Summary
Types of pericarditis
A. Acute serous
fibrinous/serofibrinous
suppurative
hemorrhagic
caseous
B. Chronic adhesive pericarditis
adhesive mediastinopercarditis
constrictive pericarditis
FIBRINOUS PERICARDITIS
Strands of fibrin
Edema
Pericardial tissue
HEMORRHAGIC PERICARDITIS
RBC
Fibrinous exudate
with mild
inflammatory infiltrate
SUPPURATIVE PERICARDITIS
Suppurative
inflammatory infiltrate
GRANULOMATOUS PERICARDITIS
Granuloma
surrounded by
lymphocytes
Mcq
A 39 years old female, a known case SLE comes
with dyspnoea and fatigue. She is diagnosed
with pericardial effusion. Pericardial tap reveals
clear, straw color fluid with few cells? What is
the type of pericarditis?
A 60 years old man had an MI 2 days back. He
now has pleuritic chest pain and pericardial
friction rub. Which type of pericarditis he is
suffering from?
A 78 years old man, a known case of purulent
pericarditis, on examination was found to have
raised jugular venous pressure, pulsus
paradoxus and enlarged heart. What is the type
of pericarditis he is suffering from?
• A 55 years old man, has 2 months history of
fever, night sweats , weight loss developed
sharp chest pain which worsens on lying
supine or on deep inspiration.
Pericardiocentesis showed blood stained
effusion.
• What are likely causes?
