Перикардит у ребёнка повторяюшейся после ОРВИ

[SKatya]

Здравствуйте! Мальчик, родился в ноябре 2014 года вес при рождении 2940 кг, рост 49. Роды естественные без осложнений на сроке 39,4 недели. На 17 день после рождения обнаружили ВПС дмжп, гемодинамически незначимый. На сегодняшний момент рост 96 см, вес 13,4кг.
В июне 2016 года на эхокг, впервые обнаружили жидкость в области перикарда, в стационаре ребёнку была проведена противовоспалительная терапия (пили ибупрофен, аспаркам и супрастин). В сентябре 2016 жидкость уже не обнаружили. Связали её появление с перенесённым ОРВИ незадолго до обследования. В этом году история повторилась... 1 июня 2017, мы планово делали эхокг в кардиоцентре, по результатам жидкости не было. 6 июня ребёнок заболел орви, после выздоровления стал жаловаться на боли в груди. После прохождения в конце июня эхокг, у нас снова нашли жидкость в полости перикарда 1,0 см за верхушкой и 0,3 см перед пж. Пролечились ибупрофеном, супрастином и аспаркамом. В июле жидкости стало меньше 0,5 см за верхушкой и 0,1 см перед пж. В конце августа ребёнок пошёл в садик, заболел ОРВИ, после орви пошли на плановое эхокг, жидкости стало чуть больше 0,5 см за верхушкой и 0,3 см перед пж.Затем жидкости стало 1,0 см и 0,9. Сейчас 0,4 и 0,3. Кардиолог снова назначила ибупрофен по 5 мл 2 раза в день и 1/4 супрастин 2 раза в день, диуретик и аспаркам.
Кардиологи говорят дмжп не может быть причиной рецидивов, ищите причину. А где ее искать?
Ещё было 2 случая, что после ОРВИ жидкость скапливалась в яичках, сначала справу, через полгода рассосалась, переболели и появилась жидкость слева.
1) Уважаемые доктора, подскажите куда и к какому специалисту нам обратится?
2) Что может быть причиной рецидивов и как с этим жить, если после каждого ОРВИ перикардиты? Мы и так как затворники, никуда не ходим чтобы не заболеть.
3) Можно ли сделать прививку от гриппа и когда, сейчас осталось небольшое количество жидкости в перикарде? В прошлом году мы прививались, но на фоне выздоровления.
Очень жду ваши ответы!

[SKatya]

Уважаемые специалисты, вопрос ещё актуален. Очень жду вашей помощи, так как здесь нам уже назначили ненавистные вами анализы на ВЭБ, герпес, и т.п. Мазки из зева и носа.

[Evgeniy_Sherbyn]

Здравствуйте. Это не инфекционное заболевание, хотя вирусные инфекции могут быть причиной рецидивов. Рецидивирующий перикардит является скорее аутоиммуннным заболевание с благоприятным исходом, которое разрешается в течение в среднем 15 лет, хотя как правило раньше.
Мы не можем заниматься его лечение онлайн, можем только дать литературу:

INTRODUCTION — Recurrent pericarditis is a common and often vexing problem for specialists in pericardial disease as well as general internists and family clinicians [ 1 ]. The term refers to a syndrome in which acute pericarditis recurs after the agent inciting the original acute attack has disappeared or has ceased to be active [ 2-5 ]. The exact recurrence rate after initial attacks of idiopathic pericarditis is unknown, but may be as high as 15 to 30 percent in patients not treated with colchicine [ 3,6-8 ]. Some patients, however, have more persistent pericarditis in which symptoms can only be controlled with steroidal therapy [ 7,9 ].

Issues related to recurrent pericarditis are reviewed here. The evaluation and management of patients with acute pericarditis are discussed separately. (See "Clinical presentation and diagnostic evaluation of acute pericarditis" .)

DEFINITION — Recurrent pericarditis is manifested by recurrence of the symptoms of acute pericarditis ( table 1 ). The major clinical manifestations of acute pericarditis are chest pain, pericardial friction rub, widespread saddle-shaped or concave upward ST segment elevation on the electrocardiogram (ECG), and pericardial effusion [ 6 ]. At least two of these features should usually be present to make the diagnosis. (See "Clinical presentation and diagnostic evaluation of acute pericarditis", section on 'Clinical presentation' .)

In the COlchicine for REcurrent pericarditis (CORE) trial, the following definition was used for recurrent pericarditis [ 10 ]:

A documented first attack of acute pericarditis.
Evidence of either recurrence or continued activity of pericarditis. Criteria for the diagnosis of recurrence included recurrent pain and one or more of the following signs: fever, pericardial friction rub, electrocardiographic changes, echocardiographic evidence of pericardial effusion, cardiac magnetic resonance imaging (MRI) evidence of inflammation of the pericardium, and an elevation in the white blood cell count, erythrocyte sedimentation rate, or C-reactive protein.
PATHOGENESIS — Most cases of recurrent pericarditis are considered to be autoimmune. Evidence supporting an immunopathologic process includes a latent period lasting for months and similarities to other autoimmune conditions including the presence of autoantibodies and responsiveness to glucocorticoid and other immunosuppressive therapies [ 11,12 ]. An infectious or systemic etiology cannot usually be identified using standard laboratory techniques without supplementary molecular biology techniques.

Recurrent pericarditis shares many features of the postcardiac injury syndrome, which may also be associated with recurrences [ 3,4 ]. (See "Pericardial complications of myocardial infarction", section on 'Postcardiac injury syndrome' .)

European investigators working in a specialized laboratory performed extensive studies to evaluate suspected recurrent pericarditis including pericardioscopy, multiple epicardial biopsies, and polymerase chain reaction (PCR) [ 13 ]. Epicardial biopsy was performed during pericardioscopy and targeted at regions that appeared abnormal. Biopsy of the subendocardium or the parietal pericardium may not be sufficient since inflammation may be limited to the epicardium (including the visceral pericardium). This intensive approach is not widely used in the United States and Europe.

The authors reported a higher prevalence of infection or reinfection (about 23 percent) than reported in other studies [ 7,13 ]. In many cases, infection may be missed on routine evaluation and only detected by PCR. These observations suggest that the proportion of cases caused by an autoimmune response may be frequently overestimated.

Based on these findings, the task force on pericardial diseases of the European Society of Cardiology established the following criteria for the diagnosis of "autoreactive" pericarditis [ 11 ]:

Pericardial fluid revealing >5000/mm3 mononuclear cells (lymphocytes and monocytes) or antisarcolemmal antibodies
Inflammation in epicardial/endomyocardial biopsies by ≥14 cells/mm2
Exclusion of active viral infection both in pericardial effusion and endocardial/epicardial biopsies
Tuberculosis, Borrelia burgdorferi, Chlamydia pneumoniae, and other bacterial infection excluded by PCR and/or cultures
Neoplastic infiltration absent in pericardial effusion and biopsy samples
Exclusion of systemic, metabolic disorders, and uremia
In patients with autoreactive pericarditis, cytokines such as interleukin (IL)-6, IL-8, and interferon gamma have been detected in the pericardial fluid but not in sera [ 14 ]. This distribution of cytokines suggests a local inflammatory process.

Familial factors may be important in some cases. A cluster of recurrent pericarditis has been described in five members of a family of German and Danish ancestry [ 15 ]. It was suggested that this might represent familial disease with possible autosomal dominant inheritance.

CLINICAL COURSE — The first symptoms of recurrent pericarditis occur at a variable time after the initial attack, but usually within 18 months [ 8,16 ]. Most patients with recurrent pericarditis are well between attacks, although some patients have a more persistent or chronic course [ 7,9 ].

The index attack is usually more severe than recurrent episodes. In the intermittent form, symptoms are found after a symptom-free interval longer than six weeks after drug withdrawal (six weeks being an arbitrarily defined interval) [ 17 ]. In incessant forms, recurrent symptoms appear within six weeks after drug discontinuation or during attempted weaning. This may be observed following NSAID use, but more commonly following glucocorticoid therapy.

The number of recurrences and the intervals between them vary considerably among patients: 40 to 50 percent have only one to two recurrences [ 10,16,17 ], usually occurring over several months to a few years or, in some cases, as long as 15 years [ 3 ] or 43 years [ 12 ]. As an example, in a study following 31 patients with recurrent pericarditis for 2 to 19 years, the duration of the recurrent process was five years or more in 19 of the patients, and eight years or more in seven [ 4 ].

The most frequent symptom of recurrent pericarditis is chest pain, which may follow exertion. Some patients report dyspnea but tamponade, which can cause dyspnea, is a rare complication, even in patients who had tamponade during the initial episode [ 4 ].

Overall prognosis is excellent for most patients with idiopathic recurrent pericarditis. Severe complications are uncommon even with multiple recurrences [ 2-4,10,12,16-18 ]. The prevalence of pericardial effusion and cardiac tamponade decrease with subsequent episodes [ 12,17,19 ]. Recurrent pericarditis is not associated with myocardial systolic dysfunction [ 12,17 ]. Although constrictive pericarditis has been reported in one family cluster with recurrent pericarditis [ 15 ], idiopathic recurrent pericarditis is not associated with constriction [ 12,17,20 ]. However, quality of life can be severely affected in patients with repeated recurrences or incessant pericarditis and glucocorticoid dependence.

Predictors of recurrence — No presenting clinical feature of an initial episode of acute pericarditis reliably predicts recurrence but the response to therapy and type of therapy for the initial episode may have some prognostic value.

The response of patients with presumed idiopathic acute pericarditis to aspirin or other nonsteroidal antiinflammatory drug (NSAID) may identify those at particular risk of recurrence. This was suggested in a review of 254 low-risk patients (patients with none of the following high-risk features: fever >38 degrees C, subacute onset, compromised immune status, trauma, oral anticoagulant therapy, myopericarditis, large or massive pericardial effusion, or cardiac tamponade) with acute pericarditis, 33 of whom (13 percent) did not respond to outpatient aspirin therapy, which was defined as persistence of fever, a new pericardial effusion, or worsening of general illness after seven days [ 6 ]. These patients, compared to those who responded to aspirin, had a much higher rate of recurrent pericarditis (61 versus 10 percent) and of pericardial constriction (9.1 versus 0.5 percent). (See "Clinical presentation and diagnostic evaluation of acute pericarditis" .)

Initial concerns that glucocorticoid therapy for acute pericarditis may promote recurrence have been confirmed in subsequent studies. The best data come from the COPE trial of colchicine therapy in patients with a first episode of acute pericarditis in which glucocorticoids were given only when aspirin was contraindicated or not tolerated [ 8 ]. On multivariate analysis, glucocorticoid use was a significant predictor of recurrence (odds ratio 4.30), an effect that may be due to promotion of viral replication [ 21 ]. The COPE trial also showed that colchicine therapy markedly reduces the rate of recurrence. (See "Treatment of acute pericarditis", section on 'Colchicine' .)

Similar findings were noted in the CORE trial of colchicine therapy in patients with recurrent pericarditis by the same investigators [ 10 ]. Previous glucocorticoid use was an independent risk factor for further recurrences (odds ratio 2.89). Similar findings have been noted in other reports [ 16,22 ]. In addition, glucocorticoid therapy may reduce the efficacy of colchicine in preventing recurrence [ 22 ]. (See 'Colchicine' below.)

[Evgeniy_Sherbyn]

THERAPY — Recurrent pericarditis can be a prolonged and frustrating disease with disabling pain and malaise. Because of this and the need to maintain compliance, effective communication with the patient is important.

The treatment of recurrent pericarditis is similar to that of the initial acute episode. Outpatient management is feasible in almost all cases [ 10,16 ]. Hospitalization should be limited to patients with high-risk features as in acute pericarditis [ 6 ]. (See "Clinical presentation and diagnostic evaluation of acute pericarditis", section on 'Determination of risk and need for hospitalization' .)

Many patients report worsening symptoms following physical exertion. Although supporting evidence is not available, it may be reasonable to restrict exertion in such patients to that necessary to perform domestic tasks and undertake sedentary work [ 17 ].

We recommend aspirin or another nonsteroidal antiinflammatory drug plus colchicine for initial therapy of recurrent pericarditis due to idiopathic or viral causes. In patients with another identified cause, specific therapy appropriate to the underlying disorder is indicated (see appropriate topic reviews). (See 'Nonsteroidal antiinflammatory drugs' below.)

The vast majority of patients will also respond to glucocorticoids (eg, prednisone ), initially given in a high dose, which is maintained for a short period and subsequently tapered. However, prolonged or frequent administration may be necessary, possibly leading to serious complications. In addition, glucocorticoid therapy may increase the rate of recurrence [ 8,10,21-24 ] even after multiple recurrences [ 22 ]. As a result, it is recommended that the use of glucocorticoids for recurrent pericarditis be limited . (See "Major side effects of systemic glucocorticoids" .)

Communication with the patient — It is important to explain to the patient the nature of the disease, the likely course, and the treatment alternatives. Specific features of the disease that should be emphasized include:

After successful treatment of a recurrence, further recurrences are possible, and may repeat, at variable intervals, for up to several years.
Recurrent episodes are not usually caused by reinfection, even among patients whose first illness was viral. It is reasonable to reassure such patients that the disease eventually disappears in most cases, almost always with no permanent sequelae.
Symptoms of cardiac tamponade, which is a rare complication of recurrent pericarditis. Constrictive pericarditis almost never occurs. (See "Cardiac tamponade" and "Constrictive pericarditis" .)
Indications for pericardiectomy as well as the reasons for delaying a decision to proceed with the operation. (See 'Role of pericardiectomy' below.)
Complications of immunosuppression. (See "Major side effects of systemic glucocorticoids" .)
Nonsteroidal antiinflammatory drugs — As with acute pericarditis, NSAIDS are part of the first-line therapy of recurrent pericarditis. The 2004 European Society of Cardiology (ESC) guidelines recommended NSAIDs for the treatment of acute pericarditis [ 11 ]. The different NSAIDs are probably equally effective but must be given in appropriate antiinflammatory doses. Gastrointestinal protection should be provided during NSAID therapy. (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity" .)

The patient's prior experience can provide a useful guide for deciding among agents. Many patients with recurrent pericarditis have tried a number of different NSAIDs at different times. If a patient reports that a specific drug has proven effective, it is reasonable to use that agent. This approach should be maintained until it is clear that NSAIDs have failed to control the syndrome, especially the pain, or that the drugs are not tolerated.

In the absence of evidence of patient preference, our first choice is aspirin (750 to 1000 mg three times daily), while ibuprofen (600 mg three times daily) is an acceptable alternative. Indomethacin (50 mg three times daily) is usually reserved for more severe cases and when first-line NSAIDs fail ( table 2 ). If the initial response to therapy is not satisfactory, the dose of the NSAID should be increased (up to the recommended daily maximum dose), or an alternative antiinflammatory agent used, until an adequate response is achieved.

The NSAID dose should be given in three doses daily to achieve better control of symptoms for one to two weeks until symptom resolution. Following symptom resolution, NSAIDs should be tapered to reduce the subsequent recurrence rate [ 6,8,10,16,25,26 ].

Aspirin (2000 to 4000 mg/day in divided doses) may be preferable in post-myocardial infarction patients or those taking aspirin as an antiplatelet agent, since ibuprofen and some other NSAIDs can interfere with the antiplatelet effect of low-dose aspirin. (See "Nonselective NSAIDs: Adverse cardiovascular effects" .)

[Evgeniy_Sherbyn]

Colchicine — Colchicine is commonly given in combination with NSAIDS for the treatment of recurrent pericarditis. The use of colchicine with or without NSAIDs can reduce or eliminate the need for glucocorticoids in patients with recurrent pericarditis. We recommend that patients with recurrent pericarditis be treated with aspirin or other NSAID plus colchicine using a regimen similar to the CORE and CORP trials (up to 2 mg on the first day, followed by 0.6 mg once or twice daily for six months) [ 10,27 ]. Colchicine should be prescribed in two doses daily rather than a single dose to reduce the risk of gastrointestinal intolerance and improve patient compliance [ 25,26 ].

The effectiveness of colchicine in patients with recurrent pericarditis has been evaluated in two randomized, placebo controlled trials:

In the CORE trial, 84 consecutive patients with a first episode of recurrent pericarditis were randomly assigned to aspirin alone or in combination with colchicine (1 to 2 mg on the first day, followed by 0.5 once or twice daily for six months) [ 10 ]. Colchicine therapy was associated with a marked and significant reduction in the primary endpoint of the rate of recurrence at 18 months (24 versus 51 percent), and a significant reduction in the secondary endpoint symptom persistence at 72 hours (10 versus 31 percent).
In the CORP trial, 120 consecutive patients with a first episode of recurrent pericarditis were randomly assigned to conventional therapy alone ( aspirin , ibuprofen , or prednisone ) or in combination with colchicine (1 to 2 mg on the first day, followed by 0.5 once or twice daily for six months) [ 27 ]. Treatment with colchicine significantly reduced the primary endpoint of first recurrence at 18 months (24 versus 55 percent with placebo, absolute risk reduction [ARR] 31 percent, 95% CI 13-46 percent) in addition to improving several secondary outcomes including persistent symptoms at 72 hours (23 versus 53 percent with placebo, ARR 30 percent, 95% CI 13-45 percent).
Similar benefits were noted with colchicine in the treatment of a first episode of acute pericarditis and in the prevention of post-pericardiotomy syndrome [ 8,28 ]. Subsequently, in a 2012 systematic review and meta-analysis of 795 patients from five randomized trials of colchicine therapy for acute or recurrent pericarditis or prevention of the post-pericardiotomy syndrome, the use of colchicine was associated with a significantly lower risk of developing recurrent pericarditis (RR 0.40, 95% CI 0.30-0.54) without a significantly higher risk of adverse events [ 29 ].

The use of colchicine in addition to an NSAID or as monotherapy for recurrent pericarditis was given a class I recommendation by the 2004 ESC guidelines, which were published before CORE and COPE [ 11 ]. The recommended dose was 2 mg/day for one or two days, followed by a maintenance dose of 1 mg/day. Nevertheless, in clinical practice, colchicine alone is not efficacious and should be given as adjunct to another antiinflammatory agent ( aspirin , NSAID, or corticosteroid).

Treatment of pericarditis and prevention of recurrence is an off label use of colchicine . Although low doses of colchicine (0.6 to 1.2 mg per day) have been safe in most patients even when given continuously over decades, there are uncommon (<1 percent) possible side effects to be considered (eg, bone marrow suppression, hepatotoxicity, and muscle toxicity) beyond the well-known gastrointestinal side effects (5 to 10 percent). Chronic kidney disease leading to increased plasma colchicine levels appears to be the major risk factor for side effects. Patient compliance may improve if a loading dose is avoided.

Glucocorticoids — Glucocorticoid therapy should generally be avoided in patients with recurrent pericarditis given the potential adverse effects and risk of increasing the likelihood of further recurrences. Glucocorticoid therapy is a double-edged sword in patients with pericardial diseases; it may have specific but rare indications, but it should be a last resort. Glucocorticoids may be considered for patients who fail NSAID and colchicine therapy; those with definite rheumatologic disease; presumed autoimmune etiology; and intolerance or contraindications to aspirin or NSAIDs (eg, pregnant patients). (See "Management of pericardial diseases during pregnancy" .)

If glucocorticoids are used, the potential benefit and harms should be discussed with the patient and possible preventive measures instituted. The patient should also be informed that some investigators believe that prednisone may, in some cases, perpetuate rather than abolish recurrences and that, once a glucocorticoid course has been completed, the aim is to taper the dose and finally discontinue prednisone therapy [ 8,10,21-24 ]. Common mistakes are to use too low a dose and, more often, to taper the dose too rapidly [ 30 ]. (See "Major side effects of systemic glucocorticoids" and "Prevention and treatment of glucocorticoid-induced osteoporosis" .)

Our approach — We use lower doses of prednisone (0.2 to 0.5mg/Kg/day; ie, 25mg for the average patient) maintained for four weeks until symptom resolution and C-reactive protein normalization. Slow tapering is recommended and colchicine can be added [ 31 ]. Toward the end of the taper, antiinflammatory treatment with aspirin or another NSAID should be introduced. In our experience, the need for other immunosuppressive treatments is rare following this therapeutic scheme.

Support for this approach comes from an observational study of 100 patients with recurrent pericarditis (51 treated with high-dose prednisone 1.0mg/Kg/day and 49 treated with prednisone 0.2 to 0.5 mg/Kg/day, with similar baseline features in the two groups). After adjustment for potential confounders, only high doses of prednisone were associated with severe side effects, recurrences, and hospitalizations (hazard ratio, 3.61; 95% confidence interval, 1.96 to 6.63) [ 32 ].

[Evgeniy_Sherbyn]

If symptoms recur, every effort should be made not to increase or reinstitute glucocorticoids, but instead control symptoms with aspirin or an NSAID. Guidelines recommend osteoporosis prevention when using these drugs, an issue often neglected in clinical practice. These issues are discussed in detail separately. (See "Prevention and treatment of glucocorticoid-induced osteoporosis" .)

Steroid dependent pericarditis — Despite guidelines and reviews recommending limiting the use of glucocorticoids in pericarditis, glucocorticoid use is widespread. There is only one retrospective study to support a regimen of high-dose glucocorticoids [ 30 ]. This study reported outcomes in 12 patients who had experienced a total of 39 relapses over the preceding 14 months despite therapy with low doses of prednisone . Patients were treated with a three-month course of high-dose prednisone (1 to 1.5 mg/kg per day for 4 weeks then gradually withdrawn). Following this aggressive regimen, one patient had a single relapse over the ensuing 42 months. When the prednisone taper was started, all patients received a five-month course of aspirin (1.6 g/day until glucocorticoid withdrawal, and then 0.8 g/day). Three patients had severe glucocorticoid-induced side effects and were switched to azathioprine or cyclophosphamide .

Following this study, reviews and European guidelines on the management of pericardial diseases have recommended the use of high doses of prednisone (1.0 to 1.5 mg/Kg/day) for one month or more for patients with recurrent pericarditis, when corticosteroids are required [ 11 ]. Unfortunately, this treatment is often quickly tapered because of fear of possible side effects. Relapses requiring prolonged glucocorticoid treatment are common with associated severe side effects.

Thus, one of the most troublesome issues in pericardial diseases is how to manage a patient with recurrent pericarditis and glucocorticoid-dependence. When high doses are administered, side effects are not uncommon and may result in the early withdrawal of the drugs. Low to moderate doses of corticosteroids (ie, prednisone 0.2 to 0.5mg/kg/day) are commonly prescribed to treat serositis in patients with rheumatologic conditions. In our experience, the use of these lower doses may be a way to minimize side effects while maintaining efficacy [ 33 ]. Slow prednisone tapering is critical and a proposed tapering scheme follows:

Daily dose >50 mg – tapered 10 mg/day every one to two weeks
Daily dose 25-50 mg – tapered 5 to 10 mg/day every one to two weeks
Daily dose 15-25 mg – tapered 2.5 mg/day every two to four weeks
Daily dose <15 mg – tapered 1.25 to 2.5 mg/day every two to six weeks
Each decrement in prednisone dose should proceed only if the patient is asymptomatic and C-reactive protein is normal, particularly for doses lower than 25 mg/day.

Combined steroid therapy — For persistent cases, it is important to try to control symptoms with a combination of traditional therapies including aspirin or an NSAID, colchicine , and a corticosteroid before resorting to more complex, and often hazardous, immunosuppressive therapies. This is especially important for idiopathic cases with an overall good prognosis, where more aggressive approaches are not warranted. Additional ways to control more severe episodes of chest pain may include IV administration of indomethacin or NSAID, corticosteroid IV bolus, and tramadol oral administration.

Intrapericardial steroids — Intrapericardial glucocorticoid therapy to achieve high local glucocorticoid concentrations may maintain efficacy while minimizing systemic toxicity. The 2004 ESC guidelines concluded that the weight of evidence or opinion was in favor of usefulness or efficacy of intrapericardial glucocorticoid therapy [ 11 ]. However, in our view, the utility of such an approach requires further investigation.

In a review of 84 patients with recurrent or persistent autoreactive pericarditis with effusion, pericardiocentesis with antibiotic prophylaxis was followed by intrapericardial administration of triamcinolone (300 to 600 mg/m2 given in 100 mL of isotonic saline at body temperature) as a single injection and then removed at 24 hours; maintenance therapy consisted of colchicine (0.5 mg three times daily) for six months [ 7 ].

This regimen led to symptomatic improvement and prevented recurrence in 90 percent of patients at three months and 84 percent at one year. Most relapses were asymptomatic and only symptomatic large effusions were retreated, using the higher triamcinolone dose. Transient cushingoid symptoms developed in 13 and 30 percent of patients given 300 and 600 mg/m2, respectively. The authors recommended beginning with the 300 mg dose of triamcinolone with appropriate analgesia at the time of instillation, followed by colchicine therapy for six months.

There are technical considerations that may limit the usefulness of intrapericardial therapy. If the patient has a large or moderate sized pericardial effusion, intrapericardial therapy is straightforward. This is usually accomplished via intrapericardial catheter following drainage of the pericardial effusion. If the patient has a small, or no pericardial effusion, pericardioscopy or the PerDUCER technique must be available to utilize this form of treatment. Neither procedure is readily available in the United States, and they are currently performed in few specialized European centers. (See "Diagnosis and treatment of pericardial effusion", section on 'Pericardial fluid analysis and biopsy' .)

[Evgeniy_Sherbyn]

Other immune therapy — In patients who do not tolerate prednisone or the small number who do not respond adequately, another immunosuppressive agent should be added. The ESC guidelines recommend azathioprine (75 to 100 mg/day) or cyclophosphamide [ 30 ]. Mycophenolate may be less toxic but evidence of efficacy in this setting is only anecdotal. Methotrexate therapy and intravenous immune globulin have also been effective but data are limited [ 12,19,34 ]. Case reports also suggest that the interleukin receptor blocker anakinra may be effective in reducing symptoms and signs of inflammation in patients with refractory symptoms [ 35-37 ].

Recurrent pain without objective evidence of disease — A difficult management problem is presented by the patient who reports recurrence of pain, but in whom no clinical or laboratory evidence of pericarditis can be elicited. This problem is most likely to occur in more chronic cases in which numerous recurrences have been suppressed by prednisone [ 23 ]. The cause of this phenomenon is unknown, but the need to withhold prednisone is clear. The problem is further complicated by the fact that, in some patients who are having a recurrence, pain precedes objective evidence of pericarditis.

It is necessary to explain to the patient that the pain may not be a manifestation of recurrence. However, patients who have experienced frequent recurrences may be hard to convince; as a result, it is important to carefully describe the clinical dilemma and explain the need to stop prednisone , or not to start a new course of glucocorticoid therapy.

Our approach is as follows:

The pain is treated by simple analgesic remedies, and steroids are avoided for several days.
The patient is then reexamined and ECG, chest radiograph, echocardiogram, sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell count are obtained [ 4 ]. Cardiac magnetic resonance (CMR) imaging with delayed enhancement should be considered if the diagnosis remains uncertain after the above testing as it is highly sensitive for pericardial inflammation. Signs of pericarditis that qualify for establishment of the diagnosis include pericardial rubs, ECG changes, a pericardial effusion, and pericardial inflammation shown by cardiac MRI. An otherwise unexplained elevation in serum CRP is also suggestive of recurrent pericarditis in these patients.
If signs of pericarditis are present, another course of treatment as outlined above is begun.
If there is no objective evidence of pericarditis, the patient is told that, although the pain is indistinguishable from that of previous episodes, pericarditis is no longer present and that it is not known why the pain has recurred. Pain management should be initiated at this point.
Pain management begins with acetaminophen , but more potent analgesics can be given, if necessary. If the pain is still not controlled, the patient is referred to a pain clinic with periodic monitoring for pericarditis.
Role of pericardiectomy — In our view, and in the view of most cardiologists specializing in the care of pericardial disease, pericardiectomy is an imperfect and unpredictable therapy which should be considered as therapy for recurrent pericarditis only after a thorough trial of medical therapy has been unsuccessful.

In persons with ongoing symptoms and relapses in spite of medical therapy, however, pericardiectomy does appear to be a safe and frequently effective treatment option. The largest reported cohort of patients with chronic recurrent pericarditis (mean six to seven relapses) included 184 patients treated at a single referral center from 1994 through 2005, with significant baseline differences noted between the two groups (patients in the surgical group had had more relapses [6.9 versus 5.5 in the medical treatment group] and were more likely to have been taking colchicine or steroids) [ 38 ]. Surgery for pericardiectomy appears to be safe, with no deaths and only two major complications (one stroke, one episode of bleeding requiring re-operation) in the immediate post-operative period and no significant difference in all-cause mortality over an average follow-up of 5.5 years. Additionally, patients treated with surgical pericardiectomy had significantly fewer relapses (9 versus 29 percent in the medical treatment group).

The 2004 ESC guidelines gave a class IIa recommendation (weight of evidence or opinion is in favor of usefulness or efficacy) to pericardiectomy only for frequent and highly symptomatic recurrences resistant to medical treatment [ 11 ]. In our practice, there are two indications for pericardiectomy:

If more than one recurrence is accompanied by cardiac tamponade, which is uncommon.
If a recurrence is principally manifested by persistent pain despite an intensive trial with medical treatment and evidence of serious glucocorticoid toxicity.
A major concern is the prospect of impaired wound healing when sternotomy or thoracotomy is performed in patients who have had a prolonged exposure to high doses of prednisone . Thus, when the decision for pericardiectomy is made, every effort should be made to maintain the patient on a glucocorticoid-free regimen for ONE YEAR preoperatively, although glucocorticoid use is not an absolute contraindication to proceeding with pericardiectomy.

[Evgeniy_Sherbyn]

Ну и герпесвирусы не являются причиной его возникновения, конечно же.

[Evgeniy_Sherbyn]

Вот информация для пациентов попроще:

RECURRENT PERICARDITIS

Approximately 15 to 30 percent of people with sudden onset (acute) pericarditis have either recurrent or persistent disease, frequently with a pericardial effusion. This risk is reduced in people who initially take colchicine and in those without a known cause of pericarditis (idiopathic pericarditis).

Signs and symptoms of recurrent pericarditis are the same as those in the initial episode. (See 'Pericarditis symptoms' above.)

Treatment with medication — Treatment of recurrent pericarditis usually includes aspirin or a nonsteroidal anti-inflammatory drug (NSAID) and/or colchicine. In addition, further evaluation and treatment of the underlying cause is appropriate. Treatment with a steroid (eg, prednisone) may be recommended if there is no response to these initial therapies. However, the risk of recurrent pericarditis may increase with use of steroids.

Side effects of steroids may include weight gain, development or worsening of diabetes, and an increased risk of infection. Thus, when steroids are used, the goal is to use the lowest possible dose for the shortest possible time. However, the steroid dose should remain steady until symptoms have resolved and then slowly tapered to reduce the risk of further recurrences.

Pericardiectomy — Pericardiectomy is a surgical procedure that removes part or most of the pericardium, the sac that surrounds the heart. This procedure is a last resort for treatment of recurrent pericarditis due to the small potential for benefit and the larger risk of persistent pain and/or surgical complications. However, it may be recommended in some situations after all other treatments have been tried.

Coping with recurrent pericarditis — Recurrent pericarditis can be a frustrating and debilitating condition. It is important for the patient and healthcare provider to discuss the nature of the disease, the likely course, and the treatment alternatives, including the following:

After successful treatment of a recurrence, further recurrences are possible. This process may be repeated at variable intervals for a prolonged period of as long as several years. However, the recurrences are most common in the first one to two years and tend to become less and less frequent and less severe in most cases.
The cause of pericarditis, if known, should be discussed. If the first illness was caused by a virus, reinfection with this virus is not likely to be the cause of the recurrence. The disease eventually disappears as mysteriously as it appeared, and almost always does so with no permanent complications.
Cardiac tamponade and constrictive pericarditis are serious but rare complications of recurrent pericarditis. Symptoms of cardiac tamponade include shortness of breath, weakness, and faintness. Symptoms of constrictive pericarditis include swelling of legs and other parts of the body (edema), fatigue, and shortness of breath.

Но, пожалуйста, не занимайтесь самолечением!

[SKatya]

Спасибо большое за долгожданный ответ. А какой специальности должен быть врач, который лечит наш диагноз? Инфекционист, генетик или кто? Есть ли какие-нибудь анализы для подтверждения аутоиммунной причины?

[SKatya]

Отдельное спасибо за статью! 👍