Symptoms, causes and treatment of pericarditis in children. Pericarditis in children: exudative, purulent, fibrous. Treatment of pericarditis in children

When fluid accumulates between the layers of the pericardial sac, a pathological condition called hydropericardium occurs. His distinctive feature– the nature of the transudate (blood passing through the vascular wall). There are no signs of an inflammatory process. Symptoms occur after significant compression of the heart: chest pain, shortness of breath, swelling of the hands and face.

For treatment, diuretics are used; if there is a large amount of fluid, a puncture is indicated.

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Causes of hydropericardium in the fetus, children and adults

The appearance of fluid in the pericardial cavity is an unfavorable sign, since most often it is an indicator of decompensation of the process. This condition can be detected even during intrauterine development. Moreover, the causes of pathology in children and adults are different.

Small hydropericardium in a child

You can see fluid in the pericardial sac as early as 20 weeks of pregnancy. Normally, the distance between the pericardial layers exceeds 2 mm. If there is more fluid than needed for lubrication, this may be a sign of:

• hydrops fetalis,
• Rh incompatibility,
• protein starvation,
• anemia,
• immunity disorders,
• infectious process,
• tumors.

In children after 3 years of age, the criterion for small hydropericardium is the divergence of the leaves up to 10 mm. It occurs in rheumatic and autoimmune diseases, heart defects,.

Etiology in adulthood

Most often, this condition complicates the course and is a sign of decompensation. In addition, factors that provoke the appearance of excess fluid in the pericardial cavity may be:

• bruises, injuries chest;
• mediastinal tumors;
• cardiac surgery;
• nephrotic syndrome;
• exhaustion, protein starvation;
• tuberculosis;
• myxedema;
• autoimmune processes;
• radiation and chemotherapy treatment.

Reactive hydropericardium during infarction

It occurs in the first days of the disease and is characteristic of transmural necrosis, that is, the damage covers all layers of the heart wall. It also happens with, which is located under the outer shell of the heart. Most often it does not last long and does not require special treatment.

Features in newborns

In premature infants, fluid may accumulate in the pericardial cavity due to prolonged catheterization of the central veins. In the vast majority of cases, the injected substance through the umbilical vein ends up in the pericardial sac.

With intense drug treatment and the need for resuscitation measures, the baby may experience a complication of hydropericardium such as. The risk increases when the catheter is in the vein for more than 5 days.

Clinical signs of the disease in newborns:

• difficulty breathing with attacks of suffocation,
• dilatation of the neck veins,
• drop in blood pressure,
• bradycardia,
• pale skin or cyanosis.

Signs of pathology

When the contents of the pericardial cavity increase to 100 ml, there may be no symptoms of hydropericardium. Patients notice deterioration of their condition only with rapid or significant fluid intake:

• feeling of heaviness in the chest
• pressing pain in the heart, worsening when bending forward,
• increasing weakness
• difficulty breathing during exercise and at rest,
• attacks of cardiac asthma (suffocation),
• swelling of the limbs and face,
• swelling of the veins of the neck with visible pulsation,
• difficulty swallowing.

The progression of the disease leads to compression of the heart by accumulated fluid - tamponade occurs. It can be suspected by severe shortness of breath, a drop in blood pressure, rapid heartbeat, the appearance of agitation, and cold sweat in patients.

When listening to the heart, the sounds become muffled and arrhythmia occurs. If resuscitation measures are not started, the outcome of tamponade may be cardiogenic shock and cardiac arrest.

Watch the video about the treatment of pericarditis:

Diagnostic methods

To confirm the diagnosis, prescribe instrumental methods diagnostics The most informative, allowing for quick implementation, are chest radiography (ultrasound of the heart).

To determine the cause of fluid accumulation, general clinical examinations of blood and urine, biochemical and immunological complexes are prescribed. When carried out, the resulting liquid is analyzed to obtain an idea of ​​the source.

X-ray

When up to 70 ml of fluid accumulates, the contours of the heart do not change. If there is more of it, then there is an expansion of the boundaries of the heart shadow, straightening of the left contour. The heart looks like a triangle and its pulsation is low.

EchoCG

Signs depend on the amount of effusion in the pericardial cavity:

• a little - free space behind the left ventricle,
• moderate amount - a gap is added on the anterior wall, which is better visible during systolic contraction,
• significant transudate – there are zones of divergence of the pericardial layers in various projections both in systole and diastole.

When tamponade appears, signs of compression of the right atrium and diastolic ventricular incompetence are detected. A picture of a floating heart appears. The inferior vena cava dilates and does not collapse on inspiration.

ECG

Ventricular complexes of low amplitude, or signs of fluctuations in QRS voltage, P and due to changes in the position of the heart, its movement in the chest with a large volume of pericardial contents.

Pericardial fluid analysis

Research is being conducted on the following indicators:

• presence of tumor cells (atypical),
• microbiological culture,
• immunological tests.

Treatment in adults and children

The occurrence of hydropericardium is an indication for urgent hospitalization. The choice of treatment tactics depends on the amount of effusion in the pericardial sac and cardiac performance indicators. If its volume is insignificant, a pericardial puncture is indicated if there are signs of growth.

Therapy is primarily aimed at the cause of this complication. For this use:

• cardiac glycosides for insufficient heart function,
• corticosteroid hormones for allergic and autoimmune processes,
• plasma expanders for cardiogenic shock,
• anti-tuberculosis drugs for a specific infection.

Prognosis for patients

Usually when timely diagnosis and the treatment provided, this pathology has a favorable prognosis. A small effusion may resolve on its own. The puncture also reduces the risk of dangerous complications. Long-term results are determined by the underlying disease against which the hydropericardium formed.

Hydropericardium occurs when non-inflammatory fluid accumulates in the pericardial sac. This process is considered secondary and complicates the course of heart disease, tumor and autoimmune diseases. It can be detected in the fetus with heart defects and blood diseases. Preterm infants are at risk of hydropericardium during central venous catheterization.

Course of the disease and medical tactics depends on the volume of contents of the pericardial cavity. A large number of transudate causes cardiac tamponade, pericardial puncture is performed to prevent cardiac arrest.

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Pericarditis in children can occur spontaneously or in the presence of other heart pathologies after surgery. It comes in several types, including exudative. Symptoms will tell parents when they urgently need help and treatment.

Pericarditis- this is fibrous, serous, purulent or hemorrhagic inflammation of the visceral and parietal layers of the pericardium, caused by infectious or non-infectious causes and often acting as a symptom of the main pathological process, less often as an independent disease.

Acute pericarditis - acute inflammation visceral and parietal layers of the pericardium of various etiologies, which can be an independent disease or a manifestation of systemic diseases.

ETIOLOGY

About 90% of isolated acute pericarditis have a viral or unknown etiology. Idiopathic acute pericarditis is diagnosed if a complete standard examination does not establish a specific etiology.

Uremic in terminal chronic renal failure (20% of cases)

Primary pericardial tumors

Secondary (metastatic) pericardial tumors

Blunt chest trauma

Postpericardiotomy occurs after heart surgery, which is accompanied by opening of the pericardium (in children 35-39% of interventions) Acute idiopathic pericarditis diagnosed when it is impossible to confirm its etiology.

EPIDEMIOLOGY

Accurate information about frequency of pericarditis absent, but in autopsies it occurs in 2-12% of cases. Its prevalence is significantly greater than clinically diagnosed. This is due to the fact that pericarditis accompanies most infectious myocarditis, endocarditis, and often occurs with systemic diseases connective tissue, rheumatism, leukemia, cancer (as metastases), after cardiac surgery, chest injuries.

Viral: enteroviruses, adeno-, CMV, herpes, EBV, influenza, Hepatitis A, B, C, parvovirus B19, HIV. Viral P. are always combined with viral M.

Bacterial: 40% - Staphylococcus aureus, Haemophilus influenzae (2nd most common in children), other cocci and Gr-flora

Tuberculous - a complication of TV of other localizations (1%).

Fungal: usually a manifestation of a generalized fungal infection infections. Autoimmune occur in almost all rheumatic diseases, more often in SLE, RA and nodular PA. Allergic

Medications are described in adults after the administration of procainamide, hydralazine, isoniazid, penicillins, etc.

PATHOGENESIS

1.Invasion of the infection into the pericardial cavity by lymphogenous or hematogenous route

2. Development of inflammatory changes caused by

Direct cytotoxic effect of the infection

Immune-mediated damage

Their combination

3. Contact inflammation and germination of tumor tissue from neighboring organs

4.Aseptic reaction under the influence of toxicants.

CLASSIFICATION

According to etiological principle

Infectious (viral, bacterial, tuberculosis)

Allergic

Autoimmune

Aseptic

According to the clinical and morphological principle

Dry (fibrinous)

Exudative (exudative)

Constrictive

Constrictive-exudative

Adhesive (adhesive, adhesive, non-constrictive)

Downstream: sharp (< 1 нед.), подострые (до 3 мес.), хронические (>3 months)

CLINIC

The clinical picture of acute pericarditis consists of the manifestations of the underlying disease and the actual symptoms of pericarditis.

Main criteria for dry (fibrinous) pericarditis

2. Pericardial friction noise

3. Dynamic changes on the ECG

Main criteria for exudative (effusion) pericarditis

1. Clinical equivalents of effusion (discomfort, pain in

chest, palpitations, shortness of breath, dry cough)

2. There is no pericardial friction noise

3. Hemodynamic disorders in the BCC, in severe cases signs of cardiac tamponade

4. Dynamic ECG changes

5. Characteristic X-ray and EchoCG changes

6. In severe cases, the results of pericardiocentesis

The pain ranges from moderate to very severe, even “heart attack-like.” They are monotonous, increase gradually, last for hours, and only temporarily weaken under the influence of analgesics. Characterized by dependence on breathing, movements, changes in body position, irradiation into left shoulder, left supraclavicular region, upper edge of the trapezius muscle. Gehrke's sign is an increase in pain when the head is quickly tilted back.

IN younger age Abdominal pain, dyspesia, vomiting, and tenderness on palpation are often noted, which simulates surgical pathology or gastrointestinal diseases.

Pain equivalents in infants: sudden motivated attacks of severe anxiety, pallor, increased shortness of breath and tachycardia, and sometimes vomiting.

Pericardial effusion. The clinic depends on its volume and rate of accumulation. With slow accumulation there are often no symptoms, with rapid accumulation there are signs of cardiac tamponade.

Signs of a hemodynamically significant effusion

1. Deafness of heart sounds

2. Disappearance of pericardial friction noise

3.Swelling of the neck veins, drop in SBP during inspiration by 12-15 mm and > (Beck's triad)

The presence of a large effusion is characterized by an increase in right ventricular HF with hepatomegaly, edema, ascites due to compression of the RA and vena cava with impaired venous flow to the RV. In this case, there is no left ventricular HF.

Pericardial friction rub at the height of pain it is gentle and limited in extent, difficult to distinguish from a short syst. noise. As fibrous deposits increase, it becomes coarse, heard over the entire AST area, is not associated with the phases of the cardiac cycle, and is heard in both systole and diastole. It has been compared to the “rhythm of a steam locomotive.”

Features:

Heard only on inspiration or expiration

Limited to the AST zone or some part of it

Practically it is not carried out even in the OST zone (“he dies where he was born”).

Inspection. A forced sitting position with the torso tilted forward (the “deep bow” pose), sometimes with the forehead resting on a pillow (Breitman’s pose) is typical. There may be a protrusion in the area of ​​the heart and xiphoid process (Auenrugger sign). There are no active respiratory movements in the epigastric region due to limited mobility of the diaphragm (Winter’s sign) Palpation. The apical impulse is weakened and shifted upward and inward from the lower left border of the OST. Its location may change due to the accumulation of fluid when

body position (Oppolzer's sign).

Percussion. The boundaries of the OST are sharply expanded and change with changes in body position. The left border of the OST can be to the left of the upper impulse (Jardin's sign), the right - to the right of the sternum in the 5th intercostal space (Rotch's sign), the AST in the lower sections comes close to the border of the OST, a sharp transition to tympanitis occurs over the compressed lung (Pothen's sign) . With large effusions behind the angle of the scapula to the left and downwards, Ewart's syndrome occurs (dullness of sound +

bronchial tone of breathing + bronchophony) due to compression of the lower lobe of the left lung by effusion accumulated posterior to the heart. When the patient bends forward, it shifts, the lung straightens, dullness disappears during percussion, and fine rales and crepitus appear (Pince's sign).

Auscultation sounds are muffled, tachycardia is noted without signs of heart failure.

Cardiac tamponade

Develops with the rapid accumulation of fluid and (or) a decrease in the extensibility of the pericardial layers. It is a phase of decompensation of cardiac compression, the filling of the chambers is disrupted, and cardiac output is reduced. Classically manifested by Beck's triad: a drop in blood pressure, an increase in central venous pressure and dullness of heart sounds.

Constrictive pericarditis

This is a complication of acute and chronic effusion pericarditis. Granulation tissue is formed, replaced by rough scars with obliteration of the pericardial cavity → increased compression of the heart, impaired ventricular filling and decreased cardiac output.

Constrictive pericarditis

Characterized by fatigue, loss of appetite, orthopnea, swelling of the neck veins, ↓ PP, in 30% of cases a paradoxical pulse is detected (decreased pulse wave on inspiration), normal or slightly increasing the border of the OST, weakening of the upper. shock, muffled tones, noise is not typical. The ECG shows a decrease in the amplitude of the QRS complexes, a decrease or inversion of T, and in 70% of patients atrial fibrillation develops. Characteristic changes on EchoCG, CT and MRI. Possible hepatomegaly portal hypertension, splenomegaly, ascites, partial nephropathy (proteinuria).

DIAGNOSTICS

Blood test in acute period nonspecific and reflects the presence of inflammation. process determined by its etiology (bacteria, viruses, non-infectious) and activity

Blood chemistry an increase in acute phase proteins also reflects the inflammatory process. Activity of cardiac isoenzymes: troponin, CPK CV, LDH 1.2 increases in half of the patients (involvement of the myocardium in the process). Other laboratory tests to clarify the etiology, Mantoux test, diaskintest, blood culture (suspicion of E), virological methods (ELISA, PCR), exclusion of intracellular infections (ELISA, PCR), testing for RF, ANF, antibodies to cardiolipin (suspicion of TS disease), ASL titer -0, thyroid hormones, etc.

The ECG changes in 90% of patients. With large effusion, total ↓ amplitude of ECG waves, trough-shaped rise of the ST segment without reciprocal inversion in other leads and without pathological Q. An early sign of acute P. is a high +T (concordant rise) in standard leads, max. in II followed by isoelectricity and inversion. Through

1-2 days ST drops below the isoline, followed by a return to it for several days (despite the ongoing inflammation process in the pericardium).

EchoCG reveals fluid in the pericardium; its quantity and even its nature can be determined by the presence of clots of fibrin, blood, air, etc.

Radiography. The pulmonary pattern is slightly changed; with large effusion, atelectatic foci may appear (usually on the left due to compression of the lower lobe

bronchus). An early sign is a change in the shape of the heart (spherical, trapezoidal, triangular), the boundaries of the shadow may also increase. MRI - to clarify the presence of effusion, if it is not detected by echocardiography. Pericardiocentesis (puncture of the pericardium) - final

diagnostic and healing method. Allows for biochemical, bacteriological, serological methods).

PERICARDIAL FLUID ANALYSIS

Density, pH, number of shaped elements blood and their composition, levels of protein, glucose, triglycerides, cytology, bacteriology.

Bacterial - the nature of the effusion is purulent, the leukocyte protein level is > 10,000/ml, due to macrophages and granulocytes.

Viral - serous effusion, protein > 30 g/l, leukocytes > 5000/ml due to lymphocytes.

Tuberculosis - serous-hemorrhagic effusion, high or medium protein level, leukocytes > 8,000 predominantly granulocytes and macrophages, mycobacterium tuberculosis.

Pathognomonic of adenosine deaminase levels > 30 U/L.

DIFFERENTIAL DIAGNOSIS

It is carried out with the accumulation of fluid of non-inflammatory origin in the pericardial cavity - Hydropericardium. It is an accumulation of fluid without fibrin admixture. As a rule, it is a consequence of heart failure with edema, ascites, effusion in the cavities (right ventricular). There is no pain in the heart area, pericardial friction noise, ECG changes are not typical for P, the volume of effusion is small, the pericardial layers are not changed. Examination of the punctate confirms that it is non-inflammatory. Cardiac tamponade does not develop.

When HF is relieved, the exudate is completely absorbed. NB! Hydropericardium can be a symptom of hypothyroidism; treatment with thyroid hormones has a + effect.

Hemipericardium occurs after blunt trauma or injury, is possible after chest compressions, when the pericardium is perforated during catheterization or cardiac probing.

Chylopericardium occurs when the pericardial cavity and thoracic cavity communicate lymphatic duct as a result of injury, congenital anomaly, as a complication of cardiac surgery, mediastinal lymphangioma, lymphangiectasia and lymphatic duct obstruction. To clarify its topic and place of communication with the pericardial cavity, a CT scan of the chest organs and lymphography are performed.

TREATMENT

Diet with potassium enrichment and restriction (sometimes complete exclusion of salt), split meals 5-6 times a day, drinking according to diuresis (per 200-300 ml< выделенного) НПВП - основа патогенетической терапии большинства перикардитов.

The timing depends on the etiology: from 2-4 weeks. up to 3-6 months

Ibuprofen is the drug of choice from 3 months of life. Dose 30-50 mg/kg/day, maximum 2.4 g. in 3-4 divided doses with ↓ doses every 3 days after normalization of CRP levels. Course 3-4 weeks.

Naproxen from 1 year to 5 years - 2.5-5 mg/kg, > 5 years - 10 mg/kg

Nimesulide > 2 years at a dose of 3-5 mg/kg in 3 doses.

Diclofenac > 6 years at a dose of 1-2 mg/kg

Indomethacin from 2 years 1-2 mg/kg in 2-4 divided doses not > 200 mg for 1-2 weeks. with a gradual dose reduction every 3 days.

Long-term use of NSAIDs requires gastroprotection: antacids, inhibitors proton pump.

Colchicine is effective in eliminating acute symptoms and relapse prevention. Children< 5 лет 0,5 мг в день в 2 приема, >5 years 1-1.5 mg per day in 2-3 doses.

Glucocorticoids indicated when NSAIDs are ineffective, except in cases of purulent P. Doses of prednisolone 1.0-1.5 mg/kg with a gradual dose reduction until discontinuation.

With proven viral P. - interferons-α and interferon inducers, specific immunoglobulins and human immunoglobulin.

With bacterial P. - protected penicillins in combination with aminoglycosides. Course up to 4 weeks. In case of severe pericarditis and the absence of a confirmed etiology, as well as the ineffectiveness of these a/b - vancomycin, 3rd generation cephalosporins.

Use diuretics with caution if there is a large amount of effusion. Prescribe furosemide 1-4 mg/kg in 2-4 doses Pericardial puncture (pericardiocentesis)) - with cardiac tamponade.

DISPANSERIZATION

For 3 years after discharge from hospital.

EchoCG - once every 6 months. in the first year

X-ray of the chest organs - once a year (monitoring the size of the heart.

Cardiac MRI is prescribed if the presence of effusion is suspected, which is not visualized by echocardiography.

Vaccination is limited to 1 year.

Pericarditis is a lesion inflammatory in nature the pericardial sac, that is, the pericardium. Pericarditis is often not an independent disease, but a complication of other pathologies. Children are diagnosed in in rare cases.

Pericarditis can be infectious (caused by some pathogen) and aseptic (occurring against the background of an allergic or systemic disease).

Pericarditis is conventionally divided into:

1. Dry or fibrous.
2. Exudative, which are divided into:

• serous;
• purulent.

1. Adhesive (develop during fusion of both layers of the pericardium).

The course of pericarditis can be asymptomatic, acute or chronic.

Causes

The lion's share of pericarditis in children is caused by viruses.

The causative agents of infectious pericarditis can be:

1. Bacteria: staphylococcus, streptococcus, tuberculosis bacillus, meningococcus, mycoplasma, etc.
2. Viruses: , Coxsackievirus, adenovirus, HIV, Epstein-Barr, etc.
3. Fungi: actinomycetes, histoplasma, etc.
4. Protozoa: malarial plasmodium, toxoplasma, amoeba, etc.
5. : echinococcus.

Aseptic pericarditis can be a manifestation of:

• after administration of an antibiotic, serum or vaccine;
• systemic disease;
• polyserositis (inflammation of many serous membranes) in acute rheumatism, rheumatoid juvenile arthritis;
• cancer or blood diseases;
• (uremia);
• traumatic injury to the heart or pericardium (including after heart surgery).

Children most often develop viral, rheumatic pericarditis, in rare cases - tuberculosis (most typical for HIV-infected children, differs severe course). In cases where causative factor not established, idiopathic pericarditis is diagnosed.

Mechanism of development of pericarditis

Pathogens of an infectious inflammatory process can enter the cavity of the heart sac in various ways:

• with blood flow;
• with lymph;
• when spreading from affected neighboring organs and tissues (with, from the lungs with a rupture of an abscess, from the pleura with tuberculous pleurisy, etc.).

Aseptic inflammation of the pericardium develops due to increased vascular permeability caused by the action of toxic substances as a result of protein breakdown (in renal failure), radiation therapy(for cancer), autoimmune process.

When a small amount of exudate sweats through the vascular wall, it is absorbed back onto the inner surface serous membrane Only deposits of fibrin in the form of villi remain in the cardiac sac - fibrinous (or dry) pericarditis develops. This form of the disease is sometimes called “villous heart.”

With significant effusion, it cannot be completely absorbed back, so it initially accumulates only in lower section pericardial cavity, causing displacement of the heart. Subsequently, the effusion can completely occupy the entire space. This is how effusion, or exudative, pericarditis develops.

When carried with blood purulent infection the effusion festeres - purulent pericarditis occurs. If the abscess ruptures and the effusion is bloody, hemorrhagic pericarditis is diagnosed. With a large volume of exudate, the heart is compressed - it develops dangerous complication: cardiac tamponade.

Exudative pericarditis is one of the most dangerous forms diseases. Compression of the heart by exudate can cause fatal outcome.

When the layers of the pericardium grow together as a result of inflammation, adhesive (adhesive) pericarditis is diagnosed, which impedes the activity of the heart.

Symptoms

Acute pericarditis can have a bright onset with symptoms appearing in the first days or a gradual development, in which signs of the disease appear after some time.

Manifestations of pericarditis may include:

• heartache of different nature: pronounced, sharp – with fibrinous pericarditis, dull aching - with exudative;
• fever;
• dyspnea;
• increased heart rate;
• dry cough;
• general weakness, feeling of fatigue;
• acrocyanosis (blueness of lips, fingers, ears);
• decreased blood pressure;
• swelling of the veins in the neck;
• swelling lower limbs.

Distinctive features of manifestations various forms pericarditis:

1. With dry (acute) pericarditis, the initial signs are fever, rapid heartbeat, pain syndrome. The pain is often localized in the navel area, the stomach is painful when palpated. At an early age, a manifestation of pain syndrome is periodic crying and restlessness of the baby.

Older children may complain of pain (almost constant) in the chest area, radiating to the neck or left shoulder. The pain intensifies deep breath, when changing body position.

In every second child with dry or fibrinous pericarditis, a pericardial friction noise of different tones can be heard for a short time to the left of the sternum (resembles the crunching of snow underfoot). It is better heard when the child is sitting. This noise is clearly recorded on the phonocardiogram.

1. With acute exudative pericarditis in a child, sharp deterioration condition, shortness of breath increases, pain in the heart bothers me. The child tries to accept forced situation(reclining or sitting, head tilted forward).

With a significant amount of effusion, hiccups, hoarseness, cough, nausea, abdominal pain, vomiting may appear - these symptoms are associated with irritation of the phrenic nerve.

Upon examination, the doctor will reveal:

• smoothness of the intercostal spaces (in children early age– bulging of the chest on the left);
• dullness of heart sounds;
• all boundaries of the heart are expanded;
• decreased maximum blood pressure with normal or increased minimum;
• paradoxical pulse (weak filling during inspiration);
• enlarged and painful liver;
• swelling is possible.

1. Chronic pericarditis can be primary or result from any form and cause of acute pericarditis. The chronic exudative process is often tuberculous. In this case, children experience shortness of breath, heart pain, and fatigue. The heart is significantly enlarged in size (sometimes a “heart hump” is formed), heart sounds are muffled, and the size of the liver is increased.

1. Chronic adhesive pericarditis may be asymptomatic if it does not cause compression of the cavities of the heart. The boundaries of the heart may be somewhat expanded. Symptoms appear when, due to the formed adhesions, the heart cavities are compressed and blood circulation is disrupted.

Children show the following signs:

• heaviness in the hypochondrium on the right;
• weakness;
• pulsation of swollen veins in the neck;
• puffiness of the face;
• cyanosis, worsening when lying down;
• possible ascites (fluid in the abdominal cavity);
• increased heart rate.

Complications

With exudative pericarditis, cardiac tamponade may develop as a result of compression by accumulated big amount exudate. The child's condition deteriorates sharply.

In infants, compartment syndrome may have nonspecific manifestations associated with high blood pressure in the superior vena cava. It causes an increase in intracranial pressure, the manifestation of which is: a bulging large fontanel (if it is not already closed), vomiting, stiffness (tension) of the neck muscles. Veins in the neck, hands and elbow fossa become visible (usually they are not visible).

In older children, anxiety, a feeling of fear, cold sweat appear, shortness of breath and acrocyanosis increase. Swelling of the face appears, and in the later stages swelling of the neck. The liver is enlarged and painful. If not provided emergency care in the form of puncture of the pericardial cavity and pumping out fluid, a fatal outcome is possible.

With adhesive pericarditis, symptoms develop that also pose a threat to the child's life.

Diagnostics

Diagnosis of pericarditis in some cases is difficult due to the unclear manifestation of symptoms.

The following can be used in diagnosis:

1. Clinical blood test: has no specific changes, may show nonspecific changes characteristic of any inflammatory process.
2. A biochemical blood test will help identify C-reactive protein, imbalance of protein fractions.
3. A bacteriological blood test is used to detect bacterial pathogens.
4. A serological blood test is used to detect antibodies to identify pathogens.
5. An ECG helps to identify functional disorders of the myocardium.
6. FCG makes it possible to detect cardiac murmurs and pericardial friction sounds.
7. An X-ray examination of the chest can detect a change in the configuration of the shadow of the heart (in the form of a ball or a triangular trapezoid) and an increase in the size of the heart, changes in the amplitude of its pulsation. When the left bronchus is compressed, atelectasis (collapse) of the lower lobe in the left lung may develop.
8. Echo-CG makes it possible to determine the presence and amount of effusion in the heart sac, the functional characteristics of the heart, the presence of adhesions, thickening of the pericardium, and fibrin deposits.
9. Most accurate diagnosis possible with a puncture biopsy of the outer membrane of the heart sac.

Treatment

Children are treated in a hospital. Bed rest is indicated for the entire period of activity in acute pericarditis. When chronic process the protective regime and limitation of physical activity depend on the child’s condition (this is decided individually by the cardiologist).

Treatment of pericarditis should be comprehensive. It depends on the form of the disease and severity.

For acute dry or exudative pericarditis with a small amount of effusion, the components of treatment are:

• painkillers for significant pain;
• drugs that improve metabolic processes in the myocardium ( vitamin complexes, potassium and magnesium preparations, Panangin, Asparkam);
• nonsteroidal anti-inflammatory drugs (Ibuprofen, Butadione, Indomethacin, etc.);
• antibiotics for an identified bacterial pathogen, taking into account its sensitivity;
• for tuberculous pericarditis, a long (6-8 month) course of two or three anti-tuberculosis drugs (Rifampicin, Isoniazid, Pyrazinamide, etc.) is administered;
• for systemic diseases, corticosteroid drugs (Prednisolone, Hydrocortisone, Dexamethasone) may be indicated;
• with the development of heart failure and stopping the activity of the process, cardiac glycosides can be prescribed, and in the presence of edema, diuretics.

In case of exudative pericarditis and a rapid increase in the amount of effusion in the heart sac, or a threat of cardiac tamponade, an urgent puncture of the pericardial cavity is indicated to remove fluid from the heart sac.

If the effusion is purulent, after its removal, the pericardial cavity is washed with saline solution with the addition of Heparin and Trasylol, an antibiotic is introduced into the cavity of the heart sac and drained. The duration of drainage depends on the further course of the disease and the dynamics of the child’s condition.

In case of compression of the heart cavities due to adhesive pericarditis, it is necessary surgical treatment in order to remove the scarred area of ​​the pericardium and adhesions.

In case of secondary pericarditis, its treatment is carried out together with the treatment of the underlying disease.

Diet

At acute process or exacerbation of chronic pericarditis, it is recommended to provide the child with a nutritious, fortified diet. Products should replenish the child’s body with potassium, selenium, fatty acids, amino acids.

The diet will speed up the restoration of damaged tissues and recovery. The volume of fluid consumed and detailed recommendations on diet will be given by a cardiologist in each specific case. However, there are general recommendations:

• meals are fractional, 5-6 rubles. in a day;
• cook dishes better method boiling, stewing or steaming;
• Food should be prepared without salt, add salt to the plate, limiting the amount of salt to 5-6 g per day;
• The body should be provided with fluid in the form of fruit drinks (especially from currants), freshly squeezed juices, herbal teas(in the absence of allergies, and agreeing with the doctor on the set of herbs, since tonic herbs are contraindicated).
• , which helps normalize cholesterol and muscle contractility, is found in pumpkin, carrots, and milk;
• , which prevents blood clots and provides protection to red blood cells that supply the heart with oxygen, is found in meat, cereals, fresh vegetables, olive oil;
• vitamin PP, which strengthens capillaries, is found in black currants, chokeberries, and citrus fruits;
• , necessary to prevent arrhythmia, are rich in cereals, eggs, milk, and meat.

It is advisable to avoid consuming foods causing bloating intestines.

Forecast

The outcome of any form of pericarditis can be:

• transition to a chronic form;
• development of the adhesive process;
• fusion of the pericardial layers, leading to the formation of an “armored heart”.

In a benign course of the disease, the process can be interrupted at some stage independently or under the influence of medications, and end with the child’s recovery.

Constrictive and purulent pericarditis have a serious prognosis. Acute development Cardiac tamponade is a serious complication that poses a threat to the child’s life. Chronic pericarditis can cause disability in children.

Prevention

Primary prevention of pericarditis has not been developed. Secondary prevention provides for the prevention of relapses of pericarditis using the following measures:

• observation of a pediatric cardiologist (or pediatrician) with carrying out Echo-CG and ECG;
• elimination of foci of infection in the body;
• dosed physical activity;
• health activities to strengthen the immune system.

Summary for parents

Pericarditis is the most common secondary lesion heart bag with possible severe complications up to fatal outcome. Much of the prognosis depends on the timing of diagnosis of the disease and treatment. That is why parents’ attention to the child’s complaints and his behavior during physical activity can help identify the disease on initial stage. Timely consultation with a pediatric cardiologist, examination and timely treatment is the key to a favorable outcome of the disease.

RCHR ( Republican Center healthcare development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2016

Other diseases of the pericardium (I31), Acute pericarditis (I30), Pericarditis with bacterial diseases classified elsewhere (I32.0*)

Pediatric Cardiology, Pediatrics

general information

Short description

Approved
Joint Commission on Healthcare Quality
Ministry of Health and social development Republic of Kazakhstan
dated June 23, 2016
Protocol No. 5

Pericarditis- inflammation of the serous membrane of the heart, which more often manifests itself as a symptom of infectious, autoimmune, tumor and other processes and less often takes the form independent disease.

Correlation of ICD-10 and ICD-9 codes:

Protocol users: pediatric cardiologists, pediatric cardiac surgeons, pediatric anesthesiologists-resuscitators, pediatricians, general practitioners.

Level of evidence scale:

Classification

According to the clinical course

:
Acute pericarditis, resolving in less than 4-6 weeks;
· prolonged (> 4-6 weeks, but< 3 месяцев без ремиссии);
· recurrent (relapse after a documented episode of acute pericarditis for 4-6 weeks or more);
· chronic pericarditis, lasting more than 3 months.

Table No. 1. Clinical and morphological classification of pericarditis

The following types of pericarditis most often occur in children:

Acute infectious pericarditis:

Viral:
· Coxsackie A;
· Coxsackie V;
· echovirus;
· adenoviral;
· caused by the mumps virus, influenza, chickenpox (including post-vaccination), mononucleosis, cytomegalovirus infection, rubella, herpes simplex virus, HIV;
· hepatitis B virus;
parvovirus B 19.

Bacterial:
· staphylococcal;
· pneumococcal;
Haemophilusinfluenza;
· meningococcal;
· streptococcal;
Salmonella;
· caused by mycobacteria against the background of HIV.

Mycoplasma;

Protozoans:
· amoebiasis;
· toxoplasmosis.

Rickettsial (Coxiella burnetii);

Pericarditis caused by physical reasons:
· hemopericardium, as well as pericarditis due to chest injuries during heart surgery;
· serous pericarditis after cardiac injury, heart surgery, myocardial infarction;
perforation of the right atrium during catheterization;
· with radioactive irradiation of the chest.

Chronic infectious pericarditis:
· tuberculosis;
· actinolmycosis;
fungihistoplasmosis;
coccidioidomycosis;
· candidiasis;
· aspergillus;
· blastomycosis.

Pericarditis with anasarca due to congestive heart failure, nephritis or cirrhosis of the liver;

Pericarditis with vasculitis, especially often with systemic lupus erythematosus (SLE), rheumatoid arthritis, rheumatic fever, as well as scleroderma, polyarthritis, Wegener's granulomatosis, Reiter's syndrome, Behçet's syndrome;

Pericarditis in metabolic disorders(uremia, myxedema, hemodialysis);

Pericarditis with congenital heart defects and cardiomyopathies;

Pericarditis with benign or malignant tumors;

Pericarditis due to foreign bodies in the myocardium;

Pericarditis, caused by drugs (using hydralazine, procainamide, phenytoin, isoniazid, phenylbutazone, doxirubicin, benzylpenicillin, tryptophan, anticoagulants, minoxidil, etc.);

Pericarditis with anemia(sickle cell, thalassemia, congenital aplastic anemia);

Pericarditis in other diseases - when aneurysms rupture, acute pancreatitis, sarcoidosis, multiple myeloma, amyloidosis, Kawasaki disease, ulcerative colitis.

Exudative pericarditis: represents the accumulation of effusion in the pericardial cavity. Typically, in children, pericardial effusion occurs without the stage of dry pericarditis, or it remains unrecognized. The child complains of chest pain, discomfort, a feeling of pressure in the chest, and palpitations. Dizziness, fainting, coughing, shortness of breath, wheezing in the lungs, and hiccups may occur. With large effusion, Beck's triad occurs - swelling of the jugular veins, muffled heart sounds and arterial hypotension. There is a decrease in blood pressure by more than 10-12 mmHg. Art. during inhalation. Pericardial pops may be heard, which are better heard in a sitting position with moderate pressure with a phonendoscope. The liver becomes enlarged and the peripheral pulse weakens.

Constrictive pericarditis its development is most typical when purulent pericarditis or pericarditis caused by tuberculosis and autoimmune diseases. At this option During the course of pericarditis, hepato- and splenomegaly, ascites, edema, swelling of the jugular veins, decreased blood pressure and low PsBP, and decreased exercise tolerance (EF) are observed. An ECG may reveal a decrease in voltage, intraventricular and AV blockade, and atrial fibrillation. When conducting echocardiography, constrictive pericarditis is characterized by thickening and calcification of the pericardium, an increase in the cavity of the left and right atrium with unchanged or reduced ventricle sizes, paradoxical movement of the interventricular septum, and limited filling of the ventricles of the heart. CT and MRI reveal thickening and calcification of the pericardium. Cardiac catheterization can establish an increase in central venous pressure. The main treatment method for constrictive pericarditis is pericardiectomy. For specific pericarditis, drug therapy using an adequate dose of combination antituberculosis therapy is recommended to prevent the progression of constriction.

Diagnostics (outpatient clinic)

OUTPATIENT DIAGNOSTICS**

Diagnostic criteria

. increased number of lymphocytes and mononuclear cells >

Complaints:
chest pain;
· discomfort;
feeling of pressure in the chest;
· heartbeat;
· dizziness;
· fainting;
· cough, shortness of breath, hiccups;

Anamnesis:

Physical examination:
· pericardial friction noise;
· swelling of the neck veins;
Beck's triad - swelling of the jugular veins, muffled heart sounds and
arterial hypotension;
pericardial “pops”, which are better heard in a sitting position
with moderate pressure with a phonendoscope;
liver enlargement;


· ascites;
cyanosis develops.

Laboratory research:

Blood analysis(in the acute period it is nonspecific, reflects the presence of an inflammatory process, changes are determined by the etiology of the process (viral, bacterial, autoimmune, allergic), its severity and activity;

Blood chemistry:
· C-reactive protein (CRP) - the degree of increase is determined by the severity and etiology of the process (viral, bacterial, autoimmune, allergic);
· the level of creatinine and serum potassium is increased with uremia;
· troponin, creatine phosphokinase MB (CPK-MB), lactate dehydrogenase (LDH) are increased (49%). The range of possible increases in troponin I levels is indicated between 1.5 and more than 50 ng/ml [level of evidence B], mainly in patients with severe ST elevation on the ECG, more often with concomitant myocarditis.

· ECG (presence of new widespread ST segment elevation and PR depression);
· EchoCG (appearance or increase in pericardial effusion).

Diagnostic algorithm

Diagnostics (ambulance)

DIAGNOSTICS AT THE EMERGENCY CARE STAGE**

Diagnostic measures:

Physical examination:
chest pain and shortness of breath;
· pericardial friction noise;
· the area of ​​cardiac dullness increases in all directions;
weakening of heart sounds;
· swelling of venous trunks in the neck;
liver enlargement;
· ascites and swelling in the legs;
· ECG with dry pericarditis: simultaneous increase in the ST segment in all leads. There is no discordance in ECG changes, which is characteristic of coronary circulatory disorders. A negative T wave may appear later, but like ST segment elevation, these T wave changes are found in all leads. With pericarditis, the QRS complex does not change, with the exception of general decline voltage of the teeth when effusion appears in the pericardial cavity.

Diagnostics (hospital)

DIAGNOSTICS AT THE INPATIENT LEVEL**

Diagnostic criteria at the hospital level**:

The diagnosis is made based on the following criteria:
. increased number of lymphocytes and mononuclear cells >5000/mm3 (autoimmune lymphocytic pericarditis) or the presence of antibodies to cardiac muscle tissue (sarcolemma) in the pericardial fluid (antibody-mediated autoimmune pericarditis);
. evidence of myocarditis on epicardial/endomyocardial biopsies (≥14 cells/mm3);
. exclusion of an active viral infection when analyzing fluid from the pericardium or in biopsy material of the endomyocardium/epimyocardium (absence of immunoglobulin M titer to cardiotropic viruses, negative polymerase chain reaction to the main cardiotropic viruses);
. exclusion of bacterial infection (bacteriological methods, PCR);
. exclusion of the presence of tumor infiltration in pericardial fluid and biopsy material;
. exclusion of systemic and metabolic diseases, uremia.

Complaints:
chest pain;
· discomfort;
feeling of pressure in the chest;
· heartbeat;
· dizziness;
· fainting;
· cough, shortness of breath, hiccups.

Anamnesis:
· with inflammatory pericarditis, the disease is usually preceded by fever, myalgia, arthralgia;
· at tumor lesion there are complaints related to this disease;
· if a tuberculous etiology of pericarditis is suspected, find out the connection with TVS;

Physical examination:
· pericardial friction noise;
· swelling of the neck veins;
· Beck's triad - swelling of the jugular veins, muffled heart sounds and arterial hypotension;
· pericardial “pops”, which are better heard in a sitting position with moderate pressure with a phonendoscope;
liver enlargement;
weakening of the peripheral pulse;
Peripheral edema appears;
· ascites;
cyanosis develops.

Laboratory research:
· clinical blood test reflects the presence of an inflammatory process, changes are determined by the etiology of the process (viral, bacterial, autoimmune, allergic), its severity and activity;
· biochemical analysis blood:
C-reactive protein - the degree of increase is determined by the severity and etiology of the process (viral, bacterial, autoimmune, allergic);
creatinine and serum potassium levels are increased with uremia;
troponin, creatine phosphokinase MB (CPK-MB), lactate dehydrogenase (LDH) are increased (49%);
· definition antinuclear factor, rheumatoid factor, antibodies to cardiolipins (for SLE, rheumatoid arthritis, etc.);
· determination of antistreptolysin-O titer (for rheumatism);
· intradermal tuberculin test (Mantoux test);
· quantiferon test (detection of latent tuberculosis);
· blood culture for suspected infective endocarditis;
· exclusion of HIV infection;
· exclusion of hemophilus influenzae infection;
· exclusion of intracellular infections (chlamydial and mycoplasma) by ELISA and PCR methods, determination of cardiotropic viruses;
· determination of the level of thyroid hormones (for hypothyroidism).

Instrumental studies:

ECG: changes in 90% of patients. In the presence of significant effusion in the pericardial cavity, a total decrease in amplitude and alternation of QRS complexes is observed.
TO early changes ECG includes:
. trough-shaped elevation of the ST segment without reciprocal depression in other leads and without pathological Q waves.
. formation of a high positive T wave (concordant rise) in standard leads, maximum in lead II, followed by isoelectricity and inversion.
. After 1-2 days, the ST interval drops below the isoelectric line, followed by a return to the isoelectric line within a few days. Changes in ST and T are dynamic, with ST returning to the isoline before the T wave becomes negative.
. With slowly progressing pericarditis, no ECG changes occur (Table 1).

EchoCG: recommended for all patients with confirmed or suspected pericardial disease.
In the fetus, fluid in the pericardium can be determined by echocardiography from the 20th week of gestation; Normally, the thickness of the liquid layer is no more than 2 mm. An increase in the amount of effusion may be a sign of fetal hydrops, Rh conflict, hypoalbuminemia, immune pathology, intrauterine infection or a tumor process.
In older children and adults, the following gradations of effusion are used:
small (divergence of pericardial leaves in diastole<10 мм)
moderate (≥10 mm behind), large (≥20 mm)
very large (≥20 mm and compression of the heart). With a large volume of effusion, the heart can move freely in the pericardial cavity (“floating heart”). These increased movements of the heart cause “pseudo” movements of its structures during echocardiography, such as pseudoprolapse of the mitral valve, pseudosystolic movement of the mitral valve forward, paradoxical movement of the interventricular septum, closure of the aortic valve in mid-systole.

Two-dimensional Echo-CG: allows us to judge the nature of the fluid in the pericardium, to suggest the presence of fibrin, blood clots, tumors, air and calcium (Table No. 7).

Transesophageal Echo-CG: informative for postoperative isolated effusions, blood clots in the pericardium, as well as for identifying metastases and thickening of the pericardium.

Echocardiographic classification of pericardial effusion (according to Horowitz):
Type A - there is no effusion into the pericardial cavity;
Type B - separation of the pericardium and epicardium (3-16 ml = 103 mm);
Type C1 - systolic and diastolic separation of the epicardium and pericardium (small effusion more than 15 ml or more than 1 mm in diastole);
Type C2 - systolic and diastolic separation of the epicardium and pericardium with weakening of pericardial mobility;
Type D - pronounced separation of the epicardium and pericardium with a large ECHO - free space;
Type E - thickening of the pericardium (more than 4 mm).

Chest X-ray:
. the pulmonary pattern is little changed;
. the presence of atelectatic areas associated with compression of the lower lobe bronchus on the left with large pericardial effusion;
. change in the configuration of the cardiac shadow: “spherical” - indicates a more active process with a rapid increase in the volume of effusion, “trapezoidal” - longer stretching of the pericardium.

Magnetic resonance imaging of the heart: prescribed if the suspected effusion is not detected by echocardiography or a specific localization of the effusion is assumed. The size of the effusion on computed tomography or magnetic resonance is usually larger than on echocardiography.

Pericardiocentesis (pericardial puncture)- carried out in case of cardiac tamponade or suspected (established) purulent, tuberculous or neoplastic pericarditis, allows for cytological, bacteriological, immunological and biochemical studies.

Analysis of pericardial fluid for exudative effusion:
. relative density - 1.018-1.20 g/l;
. protein content above 30 g/l;
. Rivalt's reaction is positive;
. of leukocytes, neutrophils and lymphocytes predominate;
. atypical cells are detected in tumor pericarditis;
. LE cells in systemic lupus erythematosus.

For bacterial pericarditis:
. the nature of the effusion is purulent;
. high protein content;
. the content of leukocytes in the pericardial fluid is more than 10,000/ml (mainly granulocytes and macrophages);
. ADA levels are not elevated.

For viral pericarditis:
. the nature of the effusion is serous, serous-hemorrhagic;
. protein content more than 30 g/l;
. leukocyte content more than 5000/ml (mainly lymphocytes);
. ADA levels are not elevated;
. assessment of pericardial effusion and/or pericardial/epicardial tissue,
by polymerase chain reaction (PCR) or in-situ hybridization [Class IIa, Level of Evidence B]:
a fourfold increase in serum antibody levels suggests viral pericarditis, but is not sufficient for diagnosis [Class IIb, Level of Evidence B];

For tuberculous pericarditis:
. the nature of the effusion is serous-hemorrhagic;
. high/medium protein content;
. leukocyte content more than 8000/ml (mainly granulocytes and macrophages in moderate quantities);
. ADA > 30-40U/l;
. detection of Mycobacterium tuberculosis in pericardial fluid or tissue and/or the presence of caseous granulomas in the pericardium.

For autoimmune pericarditis:
. the nature of the effusion is serous;
. protein content is average;
. the content of leukocytes in the pericardial fluid is less than 5000/ml (rare activated lymphocytes and macrophages in moderate quantities);
. ADA levels are not elevated.

Table No. 6. Diagnosis of constrictive pericarditis.

Notes:
a Pericardial thickening does not always mean constriction. On the arcuate side, if clinical, echocardiographic, and invasive hemodynamic assessment findings suggest constriction, pericardiectomy should not be withheld on the basis of normal pericardial thickness.
b With atrial fibrillation, diagnosis is difficult. Reversal of diastolic blood flow in the hepatic vein during inspiration is observed even when other features of the blood flow do not allow a definite conclusion to be reached.
in Patients with increased atrial pressure or a combination of constriction and restriction are characterized by respiratory changes <25%. Признаки констриктивного перикардита могут проявиться при переводе больного в полувертикальное положение на поворотном столе или положении сидя благодаря снижению преднагрузки.
d In early stages or in latent cases, these signs may be absent. Then an infusion of 1-2 liters of saline may be required to make a diagnosis. Hemodynamic changes characteristic of constrictive pericarditis may be masked or complicated by valvular or coronary heart disease.
In chronic obstructive pulmonary disease, the velocity of mitral blood flow decreases by approximately 100% during inspiration and increases during expiration. In this case, the E value is highest at the end of exhalation, and with constrictive pericarditis immediately after the start of exhalation. In addition, blood flow through the superior vena cava in chronic obstructive pulmonary disease increases with inspiration, while in constrictive pericarditis it does not change during breathing.

Table No. 7. Diagnosis of cardiac tamponade.

Notes:
a Swelling of the jugular veins is less noticeable in patients with hypovolemia or “surgical tamponade”. An increase in pressure in the jugular veins during inspiration or the absence of a decrease in pressure (Kussmaul's sign), detected during tamponade or after drainage of the pericardium, indicates a combination of pericardial effusion and compression.
b There is no paradoxical pulse if tamponade occurs with an atrial septal defect and in patients with significant aortic regurgitation.
d Sometimes blood pressure is elevated, especially in patients with pre-existing hypertension.
e Tamponade with febrile temperature may be mistaken for septic shock.
f If pericardial pressure does not decrease below atrial pressure after drainage, a combination of pericardial effusion and compression should be suspected.

Table No. 8. Criteria for diagnosing pericarditis according to echocardiography:

Diagnostic algorithm: see outpatient level.

List of main diagnostic measures:
· daily fluid balance;
· UAC;
· OAM;
· blood biochemistry: ALT, AST, bilirubin, urea, creatinine, total protein, CRP, troponins, creatine phosphokinase (CPK), antibodies to double-stranded DNA and rheumatoid factor;
· coagulogram;
· ECG;
X-ray of the chest organs;
· EchoCG;
· transesophageal echocardiography before and after surgery (if there is a sensor in the clinic).

List of additional diagnostic measures:
· microbiological examination (smear from the throat, nose, pericardial fluid, etc.);
· feces for pathological flora;
· blood for sterility;
· determination of blood acid base;
· ELISA for IUI (herpes simplex virus, cytomegalovirus, toxoplasmosis, chlamydia, mycoplasma) with determination of IgG, IgM;
· PCR for IUI (herpes simplex virus, cytomegalovirus, toxoplasmosis, chlamydia, mycoplasma) with determination of IgG, IgM;
· markers of systemic diseases;
· Mantoux test;
· Ultrasound of the abdominal organs;
· Ultrasound of the pleural cavity;
· Cardiac CT and cardiac MRI.

Differential diagnosis

Table No. 2.

Table No. 3. Diagnostic criteria for various forms of pericarditis

Table No. 4. Differential diagnosis of constrictive pericarditis and restrictive cardiomyopathy (KushwaHaetal., 1997)

RVEDP - right ventricular end-diastolic pressure.
2 LVEDP - end-diastolic pressure in the left ventricle.

Table No. 5. Differential diagnosis of constrictive pericarditis and restrictive cardiomyopathy according to catheterization of the cardiac cavities (according to J. F. AlpertAndJ. M. Rippe, 1995)

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Pericarditis in children is quite rare, but it can cause severe consequences, which means you need to be prepared to recognize the disease in a timely manner.

The risk of developing pathology exists even in newborns, and for this reason there are various reasons. Preventive measures can prevent the occurrence of this dangerous pathology, and the task of parents is to provide them.

Pericarditis is an inflammatory lesion of the outer lining of the heart., which leads to pathological disorders. is associated with 2 mechanisms - the accumulation of a significant amount of exudative fluid in the pericardial cavity and a change in the structure of the membrane tissue (thickening or fusion of leaves).

Excessive pressure appears on the heart, and the possibility of its expansion during contraction is limited. As a result, there appear serious violations in the circulatory system.

Most often, the inflammatory process has an infectious etiology. In childhood, the most common pathogens are viruses (influenza, adenoviruses, Coxsackie), but bacteria (staphylococci, streptococci, meningococci, tubercle bacilli) and fungi (candida, actinomycetes, toxoplasma) are also isolated.

The etiology of childhood pericarditis may also be aseptic in nature.. In this case, the following causes are identified: allergic reactions, juvenile rheumatoid arthritis, congenital heart defects, renal pathologies and uremia, blood diseases, autoimmune disorders, chest injuries, taking certain medications (antibiotics, vaccines, serums), systemic diseases, diabetes, polyserositis, toxic or radiation exposure.

Common forms of the disease

The nature of the inflammatory process in children differs as follows:

1. . It usually develops with infectious lesion, and therefore among children's pericarditis it is more than 80 percent.

   A characteristic feature of the pathology is the gradual accumulation of exudate in the cavity.

   This variety is very dangerous for a child, because... leads to compression of the organ and disruption of blood flow. Failure to take action may result in death.

2. . In contrast to the previous option, the pericardium dries out excessively, and fibrin (a thread-like protein) accumulates on the surface of the membrane in the form of villi. As a result, the shock-absorbing capabilities of the shell deteriorate and, accordingly, obstacles arise for normal heart contractions.
3. Adhesive or adhesive type. It manifests itself in the form of thickening of the pericardial layers and their fusion with each other. The result is compression of the heart and organ dysfunction. A dangerous variety is considered when thickened leaves compress the atria and ventricles, impairing blood circulation.
4. Purulent pericarditis. This is a dangerous infectious species caused by pathogenic bacteria. Purulent exudate accumulates in the cavity, which complicates the course of the disease.
5. Tuberculosis type. It is excited by the tuberculosis bacillus and is typical for children with tuberculosis. However, it can also be detected in children whose tuberculosis tests are negative. This form of pericarditis is very dangerous and requires effective measures.

Based on the nature of the disease and the manifestation of symptoms, the following options are distinguished:

• spicy has a characteristic sharp manifestation with pronounced symptoms for up to 7 days;
• subacute– develops within 3 months;
• chronic diagnosed when the disease lasts more than 6 months.

Medical statistics indicate some features of childhood pericarditis. Until the age of 6, pathology is detected only in an acute form, and a purulent manifestation is often recorded.

Newborns are most often infected in the first days of life, in the maternity hospital. In infants, up to 90% of the pathologies under consideration are provoked by staphylococci and streptococci. Next, priority goes to viral pathogens.

After 6-7 years of age, the course of pericarditis in children is practically no different from adults.. In etiology, acute respiratory viral infections and acute respiratory infections are especially distinguished. According to statistics, 15-22% of adolescents with pericarditis have the rheumatoid variety. In general, pericarditis occurs in 1 to 1.5 percent of children under 16 years of age.

Symptoms and signs

The manifestation of pericarditis in children depends on the type of pathology, its etiology and stage of development. Quite often the disease is asymptomatic, which makes diagnosis difficult. The most pronounced symptoms of the disease are in the acute form.

Symptoms common to all types can be identified:: pain in chest area, frequent malaise and weakness, shortness of breath, non-productive (dry) cough, swelling of the lower extremities, increased size of the jugular vein, arterial hypotension, blue discoloration on the lips and ears, increased body temperature.

It is necessary to highlight some specific signs:

1. Dry pericarditis in acute form. The onset is marked by pain and fever. The pain in children is concentrated in the navel area, and in adolescents - in the heart area with irradiation to the left shoulder. They intensify with deep inspiration. Parents may notice a reaction in babies such as crying and fussing.
2. Exudative pericarditis in acute form. arise constant pain of a dull nature, which is why the child tries to take a “half-sitting” position with his head tilted forward. Characteristic additional symptoms- hiccups, wheezing, vomiting, pain in the liver area. The progression of the disease causes an increase in intracranial pressure in children with swelling of the large fontanel.
3. Constrictive pericarditis. Particularly noticeable is the swelling and pulsation of the neck veins. There is an unpleasant sensation in the hypochondrium on the right, the face swells. The development of the process leads to an enlargement of the liver.

In adolescents, it is characterized by constant unpleasant sensations (periodically turning into pain) in the heart area. They intensify with physical activity. Quite often, slight cyanosis of the nail plates and ears appears.

Course of the pathology

The onset of the disease is associated with infection in the pericardial cavity. Further develops toxic effect on tissue cells or an immune-mediated effect occurs. It is possible to combine these mechanisms.

Pathogenesis can be caused by contact inflammation, i.e. spreading the process from nearby organs. The aseptic reaction is caused by the action of toxicants.

The disease in children usually begins acutely. When the cardiac cavities are compressed, hypodiastole develops, which leads to stagnation of blood in the vena cava, hepatomegaly and edema.

Pain syndrome appears almost from the very beginning, and in children under 4-5 years old it is felt in the navel area and is accompanied by active gas formation in the intestines.

The intensity of symptoms is largely determined by the accumulation of fluid (effusion) in the cavity. This phenomenon is evidenced by an increase in the area of ​​cardiac dullness. Compression of the heart chambers disrupts their diastolic filling. With adhesive pericarditis in a child, the acute phase can be smoothed out, and pronounced symptoms appear only at the hypodiastole stage.

In infants (up to 1 year) it increases significantly intracranial pressure with the manifestation of signs of neuralgia similar to meningitis.

At what age is it most common and how is it diagnosed?

Pericarditis can affect a child at any age. If up to 6-7 years it is only possible acute form, then after this age the disease can acquire chronic forms. The doctor makes a preliminary diagnosis after examination, palpation, percussion and auscultation of the child..

Upon examination, smoothness of the intercostal zone is revealed. In infants, the chest may protrude on the left side. Absent active phase respiratory movement in the epigastric zone. An abnormal pulse with weak filling during inspiration, dullness of heart sounds, and expansion of the boundaries of the organ are detected.

The diagnosis is confirmed by conducting the following studies:

1. General and biochemical blood tests to confirm the presence of an inflammatory process and determine its nature.
2. ECG. The change in the amplitude and width of the teeth and the ST segment is established.
3. Echocardiography reveals fluid accumulation and the appearance of fibrin.
4. Radiography clarifies changes in organ size and reveals atelectatic foci.
5. MRI and computed tomography provide complete information about the pathology.

In some cases, there is a need to use invasive diagnostic methods. Pericardial puncture (pericardiocentesis) is performed when high risk severe complications and planning surgical intervention. We talked in more detail in another article.

To unify approaches to the diagnosis and treatment of childhood pericardium, the Ministry of Health of the Russian Federation has developed Federal clinical recommendations for the provision of medical care children with pericarditis. They were approved by the Congress of Pediatricians on 02/14/15. Treatment priorities are based on the grades of recommendations and levels of evidence based on decisions of the European Society of Cardiology.

Treatment and prognosis

The main difference in treatment for children from treatment for adults is mandatory hospitalization, the use of invasive methods only in extreme, particularly severe cases, the prescription of drugs taking into account age restrictions and strict monitoring of the treatment process and the development of the disease.

Conservative methods include the establishment of a special regime and diet, etiotropic, anti-inflammatory and symptomatic therapy.

Basic therapy is aimed at eliminating the inflammatory response. The drugs prescribed are Ibuprofen, Aspirin, Diclofenac, Indomethacin. At the same time, the root cause of the disease is affected. Most often, antibiotics are prescribed (Penicillin, Ampicillin, Amoxicillin).

For rheumatoid pericarditis, glucocorticoids (Prednisolone) are used. If a pathology of the tuberculosis type is detected, then an injection of Streptomycytin is performed.

Long-term active therapy requires gastroprotection, for which antacids and proton pump inhibitors are prescribed. Colchicine is used to eliminate the risk of relapse.

The prognosis for the recovery of children with timely initiation of treatment is favorable. The greatest concern is advanced adhesive or constrictive pericarditis and especially the complication of cardiac tamponade.

With a mild course of the disease, symptoms can persist for 14-16 days, and the effusion is removed in 9-12 days without complications.

Purulent processes are especially dangerous for infants. In this case, there is a risk of death, and the probability of chronicity of the process is estimated at 15-18%.

Possible consequences

Pericarditis in children is dangerous due to its complications. The progression of exudative type pathology with excessive accumulation of effusion can cause cardiac tamponade. Severe cardiac dysfunction appears, venous and intracranial pressure increases.

Tamponade is characterized by swelling of the face and neck, acrocyanosis, cold sweating, and severe shortness of breath. If the fluid is not removed immediately, death is possible.

In the case of adhesive type pericarditis, the development of the process inevitably leads to heart failure, which is a clear threat to life. Liver damage should be considered as a late complication. There are signs of false cirrhosis.

In some cases, the disease is asymptomatic and therefore cannot be detected in a timely manner. Despite the absence of external manifestations, structural changes occur that are irreversible. The pathology gradually becomes chronic.

With age, under the influence of a number of factors, this process can significantly worsen the quality of life. A person cannot be exposed to significant physical activity and may partially lose working capacity. This leads to disability of the patient.

Primary and secondary prevention

Primary prevention of pericarditis in a child should begin during pregnancy. It is necessary to ensure the prevention of fetal infection and periodic examination of pregnant women. After birth, anti-tuberculosis vaccinations, prevention of colds, acute respiratory viral infections and influenza, as well as hemophilus influenza infections play an important role.

If foci of infection are detected in a child (for example, tonsillitis), their timely sanitation is necessary. Immunological rehabilitation is indicated for frequently ill children. All children are recommended to exercise and exercise.

Secondary prevention is necessary after the child has been cured of the disease in question.. First of all, it is necessary to ensure constant control and clinical observation.

For such children, it is important to conduct regular. Physical exercise must be dosed. Special exercise therapy can play a beneficial role, but the legs must be developed with the participation of a specialist.

Optimal nutrition involves a gentle diet, and the diet should be agreed upon with a nutritionist.

Pediatric pericarditis can occur at any age, starting from birth. Parents need to be vigilant and observant, and when the first signs appear, show the child to the doctor. With timely initiation of treatment, the prognosis for curing pericarditis is quite favorable. You can't miss the moment.