General information on chronic pericarditis

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By Sola Ogundipe & Chioma Obinna
What is chronic pericarditis? Chronic pericarditis is an inflammation (swelling) of the pericardium lasting for more than three months. The pericardium is a sac that surrounds your heart and its large blood vessels.

It holds your heart in the center of the chest and protects it from infections in your body. A small amount of clear fluid between the heart and the sac keeps them from rubbing against each other. This fluid may increase in amount and have other materials, such as pus during this condition.

What causes chronic pericarditis?

Chronic pericarditis may start as an acute condition, where the symptoms appear suddenly and worsen quickly. In some cases, the cause is unknown. One’s condition may have gotten worse over time. Pericarditis may be caused by any of the following:

Renal failure is an established cause of pericardial disease, including pericarditis and pericardial effusions, and a less frequent cause of chronic constrictive pericarditis

Renal failure is an established cause of pericardial disease, including pericarditis and pericardial effusions, and a less frequent cause of chronic constrictive pericarditis

* Damage to the sac: Injuries or accidents, such as a hard blow to the chest, may damage the sac.
* Germs: Germs, such as viruses and bacteria, may cause this condition. Infection in other areas of the body may also spread and reach the sac.

* HIV infection: When you have human immunodeficiency virus (HIV), your immune system is weak and cannot fight germs. You are at greater risk for getting infections.

* Medicine: Medicines such as those used to treat cancer and infection.
* Procedures: Procedures such as a radiation therapy on the chest, or hemodialysis for kidney failure.
* Kidney failure: Fluid and chemicals may build up in your body and around your heart when your kidneys fail.

* Tuberculosis: This is a condition where a bacteria (germ) causes infection (swelling) in your lungs. These germs may spread and reach the heart sac.

* Other conditions: Autoimmune diseases, cancer or a heart attack may damage or increase the amount of fluid in the sac. If you are pregnant, your growing baby may push on your heart and cause problems with your heart.

What are the signs and symptoms of chronic pericarditis?

Your signs and symptoms may have been coming and going for a long time. You may have any of the following:
* Fatigue (feeling very tired most of the time) and getting tired very easily.
* Fever.
* Pain in your chest that becomes worse when lying down.
* Palpitations (fast, strong heartbeats).
* Trouble breathing.

How is chronic pericarditis diagnosed?

Your caregiver will examine you and ask about past medical problems. He will listen very carefully to your heart and check for problems. You may also have any of the following tests:

* 12-lead ECG: This test, also called an EKG, helps caregivers look for damage or problems in the heart. Sticky pads are placed on your chest, arms and legs. Each sticky pad has a wire that is hooked to a machine or TV-type screen. A short period of electrical activity in your heart muscle is recorded. Caregivers will look closely for certain problems or changes in how your heart is working.

* Blood tests: You may need blood taken for tests. It can give your caregivers more information about your health condition.

* Echocardiogram: This test is also called an echo. It uses sound waves to show pictures of the size and shape of your heart and how your heart moves when it is beating. An echo can also see fluid around the heart or problems with your heart valves.

* Imaging tests: Tests such as chest x-rays, computerized tomography scan (CT scan), or magnetic resonance imaging (MRI) take pictures of your chest. This shows caregivers fluid around your heart.

* Pericardial biopsy: This procedure is used to take a small piece of your heart sac. Your caregiver may make an incision (cut) through your chest and slice a small piece of the sac. It is then sent to a lab for tests.
* Pericardiocentesis: This procedure uses a long needle to take a fluid sample from the sac. The sample is sent to a lab for tests. This procedure can also remove extra fluid and decrease or take away your symptoms.

* Transesophageal echocardiogram:

A transesophageal echocardiogram (TEE) is a type of ultrasound that shows pictures of the size and shape of your heart.

It also looks at how your heart moves when it is beating. These pictures are seen on a TV-like screen. You may need a TEE if your heart does not show up very well in a regular echocardiogram. You may also need a TEE to check for certain problems such as blood clots or infection inside the heart.

You will be given medicine to relax you during a TEE. Caregivers put a tube in your mouth that is moved down into your esophagus (food pipe). The tube has a small ultrasound sensor on the end. Since your esophagus is right next to your heart, your caregiver can see your heart clearly.

How is chronic pericarditis treated?

Your caregiver will have to treat medical conditions causing your condition or making it worse. You may have any of the following:

* Medicines: Antibiotics: Antibiotics may be given to help treat or prevent an infection caused by germs called bacteria., Nonsteroidal anti-inflammatory medicine: These medicines are also called NSAIDs. They help decrease pain, inflammation (swelling), and a high body temperature (fever).

Proton pump inhibitors: These are used to help prevent unwanted side effects from taking NSAIDs, such as an upset stomach.

Steroids: Steroid medicine may be given to decrease inflammation, which is redness, pain, and swelling.
* Treatment options:

You may need any of the following procedures:
Balloon pericardiotomy: This uses a small balloon to make a hole in your heart sac to let out fluid.
Pericardial biopsy: A piece of your heart sac is taken to make a small hole and drain fluid from the sac.

Pericardiectomy: All or a part of a very badly scarred heart sac is removed. Your caregiver makes an incision (cut) through your chest and removes or repairs areas that are damaged.

Pericardiocentesis: Extra fluid in the sac is removed to help your heart beat better. A long thin needle is inserted in your chest, up to the space between your heart and the sac. A certain amount of fluid is removed through the needle.

1st Study on Management of  Pericarditis in Africa

The first African multi-center prospective observational registry of the clinical presentation, diagnostic evaluation, initial treatment, and outcome of patients with suspected tuberculous pericarditis in the HIV era was conducted in 2005.

In the study by Dr. Abolade Awotedu of the University College Hospital (UCH) and 17 other consultant cardiologists from various countries of the world, on clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era and entitled: Investigation of the Management of Pericarditis in Africa (IMPI Africa) Registry, it was noted that pericarditis is a common disorder with multiple causes and presents in various clinical settings.

Tuberculosis is said to be responsible for more than 50 per cent of cases of pericarditis in developing countries where tuberculosis remains a major public health problem.

According to the study, by contrast, Mycobacterium tuberculosis infection accounts for less than 5 per cent of cases of pericarditis in industrialised countries. In Africa, the incidence of tuberculous pericarditis is said to be rising as a direct result of the human immunodeficiency virus (HIV) epidemic. Hence a strong association between HIV infection and tuberculous pericarditis in endemic regions, where 40–75 per cent of patients with large pericardial effusion (suspected to be tuberculosis) are infected with HIV.

However, the study pointed out that the effect of HIV infection on the clinical presentation, response to treatment and outcome of patients with tuberculous pericarditis is not well characterised.

Experts noted that HIV infected patients with tuberculous pericarditis have been found to be more likely than HIV negative patients to have disseminated tuberculosis, raising the possibility that dissemination may worsen long-term outcome.

They said preliminary evidence suggests that HIV infection may be associated with higher mortality in tuberculous pericarditis; mortality with anti-tuberculosis chemotherapy ranged from 8 per cent to 17 per cent in the pre-HIV era, whereas higher mortality rates of 17–34 per cent have been reported in HIV infected individuals.

Worst American President’s medical history

Of all recent American Presidents, the one with the worst health was John F. Kennedy. As a child he had numerous illnesses, including scarlet fever, bronchitis, whooping cough, diphtheria, allergies, and asthma. He had a duodenal ulcer, was colour-blind in one eye, and later lost his hearing in one ear.

He suffered from a bad back throughout his life and almost died from back surgery in 1954. Kennedy wore a back brace, was fitted for an elevated heel on one shoe, and often used crutches. He used a hydraulic lift to enter and exit Air Force One.

He did not take painkillers but used cortisone to reduce inflammation. He would swim in the White House heated pool twice a day and take three hot baths daily to alleviate his pain. Kennedy also suffered from adrenal insufficiency (later diagnosed as Addison’s disease, a progressive deterioration of the adrenal glands that made it difficult for him to fight infections) and had malaria and sciatica.

What was thought to be a suntan epitomizing good health was actually the bronzed skin typical of people suffering from Addison’s disease. To treat the disease, Kennedy took medication (cortisone, a steroid hormone) while in the White House.

There is no evidence that his use of the medication affected his ability to make decisions. There is, however, an ethical issue involved because Kennedy and his doctors denied that he had Addison’s disease or was being treated for it.

Presidents whose medical history was concealed

Chester Arthur who succeeded James Garfield as American President in 1881 was the first president to lie about his health. Within a year, he began feeling ill and was diagnosed with Bright’s disease, a kidney disorder. In his last two years, he was frequently confined to bed. To ease his pain he took trips to warm climates. On one trip to Florida ,he nearly died. When he was asked by reporters about his health he insisted he was in tiptop shape.

Grover Cleveland, as his second term began, complained that the inside of his mouth felt odd. A doctor discovered he had cancer. He later underwent an operation to remove the upper part of his jaw. Overweight and ill, he was operated on in secret aboard a yacht off the New York coastline. His doctors worried their overweight patient could die. A rubber plate was inserted in his jaw to replace the cancerous bone that had been removed. Cleveland recovered at his vacation home but when asked about his medical condition, he sent out an official to lie.

Woodrow Wilson suffered two strokes in the 1890s, more than a decade before he became president. He never revealed this to the public. Toward the end of his second term, he was incapacitated by a series of strokes. He was confined to bed for most of the rest of his term. His wife reportedly ran the government in his absence. When questions were raised about his health, she insisted  he was conducting affairs as always.

Franklin Delano Roosevelt revealed  he had suffered polio in the 1920s but never let the public know that he had failed to fully recover.

To maintain the fiction that he had the use of his legs, photographers were forbidden to take his picture while he was getting in and out of the presidential car. Rumors swirled around him in 1944 that he was unfit to serve a fourth term.

To demonstrate his vigour in the campaign, he subjected himself to a tour of New York in an open car during a driving rain storm but died in April 1945, shortly after being sworn in as president.

In 1949, Dwight Eisenhower complained of serious chest pain and was confined to a hospital bed in Florida for more than a month.

It is now believed he had suffered his first heart attack. Shortly after he took office as president, he again suffered serious chest pains. His press secretary told the press that he had eaten something that disagreed with him, when in all likelihood he had suffered a second heart attack.

In 1955, he was on vacation in Denver when he suffered yet another heart attack. His doctor initially told the press that Ike had “digestive upset”. Only after it was obvious that the president had suffered a massive cardiac arrest was the truth revealed.

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