Open Access Research BMJ Open: first published as 10.1136/bmjopen-2015-009141 on 24 November 2015. Downloaded from Is acute idiopathic pericarditis associated with recent upper respiratory tract infection or gastroenteritis? A case–control study Florian Rey,1,2 Cecile Delhumeau-Cartier,3 Philippe Meyer,1 Daniel Genne4 To cite: Rey F, Delhumeau- ABSTRACT et al Strengths and limitations of this study Cartier C, Meyer P, .Is Objectives: The aim of this study was to assess the acute idiopathic pericarditis association of a clinical diagnosis of acute idiopathic ▪ associated with recent upper This is, to the best of our knowledge, the first pericarditis (AIP), and a reported upper respiratory respiratory tract infection or study specifically examining the association gastroenteritis? tract infection (URTI) or gastroenteritis (GE) in the between a diagnosis of acute idiopathic pericar- A case–control study. BMJ preceding month. ditis and a recent preceding viral illness. Open 2015;5:e009141. Design: Patients who were hospitalised with a first ▪ The originality of this case–control study was in doi:10.1136/bmjopen-2015- diagnosis of AIP were retrospectively compared with a the use of detailed clinical information obtained 009141 control group of patients admitted with deep vein via comprehensive admission notes in both thrombosis (DVT), matched by gender and age. groups, which reduced potential bias in the ▸ Prepublication history and Setting: Primary and secondary care level; one analysis. additional material is hospital serving a population of about 170 000. ▪ The relatively small sample size of the study available. To view please visit Participants: A total of 51 patients with AIP were (n=46 in each group) is a limitation, even though the journal (http://dx.doi.org/ included, of whom 46 could be matched with 46 the results were statistically significant. 10.1136/bmjopen-2015- patients with control DVT. Only patients with a ▪ A prospective collection of data in cases and 009141). complete review of systems on the admission note controls would have been more accurate com- Received 19 June 2015 were included in the study. pared to our retrospective design. Revised 13 October 2015 Main outcome measure: Conditional logistic Accepted 15 October 2015 regression was used to assess the association of a clinical diagnosis of AIP and an infectious episode (URTI or GE) in the month preceding AIP diagnosis. diagnosed as acute idiopathic pericarditis http://bmjopen.bmj.com/ (AIP), which is supposed to be viral in most Results: Patients with AIP had more often 1–3 experienced a recent episode of URTI or GE than cases. Several viruses have indeed been patients with DVT (39.1% vs 10.9%, p=0.002). The identified in AIP with effusion even though multivariate conditional regression showed that AIP microbiological investigations are not rou- was independently associated with URTI or GE in the tinely performed in clinical practice.45Its last month preceding diagnosis (OR=37.18, 95% diagnosis is based on four clinical criteria CI=1.91 to 724.98, p=0.017). (pericarditic chest pain, pericardial rubs, Conclusions: This is, to the best of our knowledge, new widespread ST-elevation or PR depres- on October 1, 2021 by guest. Protected copyright. the first study demonstrating an association between a sion on ECG and new or worsening pericar- recent episode of URTI or GE and a clinical diagnosis dial effusion) of which at least two are of AIP. required.1 Prior studies have shown that 1Division of Cardiology, University Hospital of typical chest pain was present in more than Geneva, Geneva, Switzerland 95% of cases, while the other three criteria 367 2Department of Internal were more variable. Medicine, Neuchâtelois INTRODUCTION According to current guidelines on peri- Hospital, La Chaux-de-Fonds, Acute pericarditis refers to inflammation of cardial disease, signs and symptoms of sys- Switzerland 3University Hospital of the pericardial layers and possible increased temic infection such as fever or leucocytosis fl 1 1 Geneva, Geneva, Switzerland production of pericardial uid. It is encoun- may be present in acute pericarditis. AIP is 4Department of Internal tered in about 0.1% of hospitalised patients thought, by the medical community, to often Medicine, Hospital Center of and 5% of patients admitted to the emer- be preceded by a recent upper respiratory Bienne, Bienne, Switzerland gency department for non-ischaemic chest tract infection (URTI) or gastroenteritis 1 Correspondence to pain. Acute pericarditis is considered to be (GE), but this association has never been Dr Philippe Meyer; the most common form of pericardial demonstrated. The aim of this study was to [email protected] disease with at least 80% of all cases examine the association of a recent (last Rey F, et al. BMJ Open 2015;5:e009141. doi:10.1136/bmjopen-2015-009141 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2015-009141 on 24 November 2015. Downloaded from 1-month period) episode of URTI or GE and the clinical nitrogen level (>7.1 mmol/L) and eosinophilia diagnosis of AIP. This association might be helpful for (>0.39 G/L). Other variables were also retrieved in both physicians in the differential diagnosis of non-ischaemic groups including: presence of heart disease (valvular chest pain in the emergency room. and/or ischaemic heart disease), atrial fibrillation, car- diovascular risk factors, antiplatelet therapy, heart rate, respiratory rate, high white cell count (>9.8 G/L) and METHODS high C reactive protein (CRP) (>5 mg/L). Study design This was a case–control study where patients hospitalised Study patients with a diagnosis of AIP were compared with a control AIP group group of patients admitted with deep vein thrombosis Every patient with a diagnosis of AIP, and aged 16–85 (DVT). Patients of the two groups were matched by years, was included. A diagnosis of AIP was retained in gender and age (age difference ≤3 years). We retro- those having at least two of the four following criteria: spectively analysed data from November 2006 to typical chest pain (sharp and pleuritic, improved by November 2011 of all consecutive patients admitted for sitting up and leaning forward), pericardial friction rub AIP and DVT at the Neuchâtelois Hospital (a superficial scratchy or squeaking sound best heard (Switzerland), which serves a population of about with the diaphragm of the stethoscope over the left 170 000. The main outcome was the association of a sternal border), ECG changes (new typical widespread diagnosis of AIP or DVT with an infectious episode ST elevation or PR depression) and new or worsening (URTI or GE) in the month preceding diagnosis. pericardial effusion.1 Idiopathic aetiology was defined as International Classification of Diseases (ICD) 10 codes the absence of any other known aetiology including bac- of hospitalisation for AIP and DVT were extracted from terial (purulent), myocardial infarction or Dressler syn- the hospital electronic database. All demographic and drome, hyperuricaemia, neoplasm, systemic disease, medical data were retrieved from medical written intoxication and trauma.1 Patients with acute pericarditis records between November 2011 and July 2014. caused by one or more of these aetiologies were Only patients admitted in internal medicine wards excluded. The diagnosis of myopericarditis was also were selected. There is no cardiology department at the accepted and defined as an elevation of troponin I Neuchâtelois Hospital. However, patients with acute peri- (>0.045 μg/L) in addition to the diagnosis of pericardi- carditis who need to be hospitalised are admitted in tis.10 Microbiological investigations were not required. internal medicine wards where cardiologists act as The following criteria were considered to rule in bacter- consultants. ial infection aetiology: presence of a left shift (increase All medical charts contained a comprehensive admis- of band forms) in the white cell count, positive blood sion note with structured items concerning medical culture, and history and clinical presentation compatible history and physical examination. Patients with admis- with a bacterial infection. If a patient had several epi- http://bmjopen.bmj.com/ sion notes containing a complete review of systems sodes of pericarditis during the study period, we only including an accurate description of pulmonary, digest- considered the first episode. ive and systemic symptoms and their time of occurrence, were retained (see online supplementary appendices). Control group URTI was defined as an acute infection involving the Patients hospitalised for a DVT were chosen as a control nose, paranasal sinuses, pharynx and larynx. The proto- group because DVT is not known to be associated with type was the illness known as the common cold in add- viral URTI or GE.11 Moreover, patients hospitalised for a 8 ition to pharyngitis, sinusitis and tracheobronchitis. GE DVT in internal medicine wards often had comprehen- on October 1, 2021 by guest. Protected copyright. was defined as diarrhoeal disease (≥3 liquid stools per sive admission notes including a complete review of day) of rapid onset that lasted <2 weeks and possibly systems. Finally, the number of medical records of accompanied by nausea, vomiting, fever or abdominal patients with DVT was large enough to be used as a pain.9 control group. In patients with AIP, several specific variables known as Every consecutive patient with a diagnosis of DVT, and predictors of poor outcome6 were collected: number of aged 16–85 years, was