🫀 Chapter 489.1: Acute Pericarditis
Nelson's Textbook of Pediatrics 22e | Viral pericarditis · Chest pain · Friction rub · ECG · Echocardiogram · NSAIDs · Colchicine · Pericardial effusion · Tamponade · Postpericardiotomy
📚 Reference: www.paeds.online — Paediatric Resource Hub
📌 Acute Pericarditis – DefinitionInflammation of the pericardial layers. Most common etiology: viral (coxsackie, echo, adenovirus, influenza, EBV, CMV, COVID-19). Others: idiopathic, postpericardiotomy, autoimmune (SLE, JIA), uremic, bacterial (S. aureus, TB).
📌 Clinical Triad1. Chest pain (sharp, pleuritic, positional – worse supine, better leaning forward). 2. Pericardial friction rub (pathognomonic, scratchy, to-and-fro, best heard LLSB). 3. Fever.
📌 ECG StagesStage I: diffuse ST elevation (concave up) with PR depression. Stage II: normalization of ST/PR. Stage III: diffuse T-wave inversion. Stage IV: normalization.
📌 Laboratory FindingsElevated CRP, ESR. Mild troponin elevation (myopericarditis). Leukocytosis. Viral serologies if suspected. Blood cultures if bacterial.
📌 EchocardiogramPericardial effusion (echo-free space). Assess for tamponade (RV collapse, IVC plethora). Normal LV function (differentiates from myocarditis).
📌 Cardiac Tamponade – SignsBeck's triad: hypotension, JVD, muffled heart sounds. Pulsus paradoxus >10 mmHg. Emergent pericardiocentesis.
📌 Postpericardiotomy SyndromeFever, pericarditis, pleural effusion 1-6 weeks after cardiac surgery. Self-limited. Aspirin/NSAIDs first-line.
📌 Treatment – First-lineNSAIDs (ibuprofen 30-50 mg/kg/day) for 1-2 weeks with taper. Colchicine for recurrent pericarditis (reduces recurrence). Avoid corticosteroids (risk of chronicity).
📌 Recurrent PericarditisRelapse after symptom-free interval. Colchicine reduces recurrence by 50%. Refractory: anakinra (IL-1 inhibitor) or corticosteroids.
📌 Purulent (Bacterial) PericarditisToxic appearance, high fever, tamponade. Emergent pericardiocentesis + IV antibiotics (vancomycin + ceftriaxone). Surgical drainage if loculated.
🔍 Step 1: Recognize pain characteristics
Sharp, retrosternal, pleuritic (worse with deep breath), worse supine, better leaning forward. Radiates to shoulders, neck, back. May mimic MI.
📈 Step 2: Physical examination
Pericardial friction rub (scratchy, to-and-fro, best heard at LLSB with patient leaning forward, breath held in expiration). Tachycardia, fever.
🩺 Step 3: ECG
Diffuse ST elevation (concave up) in I, II, aVF, V2-V6. PR depression (atrial injury). Reciprocal ST depression only in aVR.
🔄 Step 4: Laboratory & Imaging
Troponin normal or mildly elevated (myopericarditis). CRP, ESR elevated. Echocardiogram: rule out effusion/tamponade, assess LV function.
🚨 Step 5: Identify etiology
Viral prodrome, recent surgery (postpericardiotomy), autoimmune symptoms, uremia, TB risk, trauma. Pericardiocentesis if large effusion/tamponade.
1️⃣ Acute pericarditis – Medical therapy (outpatient if stable)
▪ NSAIDs: ibuprofen 30-50 mg/kg/day (max 2.4 g/day) for 1-2 weeks, then taper over 1-2 weeks.
▪ Aspirin 50 mg/kg/day (especially postpericardiotomy).
▪ Colchicine: 0.5-1 mg/day (weight ≥35 kg) for recurrent pericarditis (reduce recurrence).
▪ Activity restriction: avoid strenuous exercise until symptoms resolve.
2️⃣ Pericardial effusion – No tamponade
▪ Small/moderate asymptomatic: observe, treat underlying cause. Repeat echo in 1-2 weeks.
▪ Large symptomatic effusion: pericardiocentesis for relief of symptoms.
3️⃣ Cardiac tamponade – Emergent
▪ Pericardiocentesis (echo-guided) – life-saving.
▪ IV fluids (increase preload). Avoid diuretics, vasodilators.
▪ Surgical pericardial window if recurrent or loculated.
4️⃣ Purulent (Bacterial) Pericarditis
▪ Emergent pericardiocentesis + drain placement.
▪ IV antibiotics: vancomycin + ceftriaxone (cover S. aureus, S. pneumoniae, H. influenzae).
▪ Surgical drainage if loculated or persistent.
5️⃣ Postpericardiotomy syndrome
▪ Aspirin (50 mg/kg/day) or NSAIDs.
▪ Colchicine if recurrent.
▪ Corticosteroids for severe/refractory (prednisone 1 mg/kg/day).
6️⃣ Corticosteroids – Avoid if possible
▪ Use only if refractory to NSAIDs/colchicine, autoimmune etiology, or postpericardiotomy severe.
▪ Risk of chronicity/recurrence when tapered.
7️⃣ Transition & long-term follow-up
▪ Recurrent pericarditis: colchicine long-term. Refractory: anakinra (IL-1 inhibitor).
▪ Constrictive pericarditis rare complication.
▪ Transition to adult cardiology for chronic/recurrent cases.
❓ Reflex prompt 1: A 12-year-old with sharp chest pain, worse supine, better leaning forward. ECG shows diffuse ST elevation with PR depression. Most likely diagnosis?
✅ Answer: Acute pericarditis. Treat with ibuprofen, echocardiogram to exclude effusion.
❓ Reflex prompt 2: A 6-year-old post-cardiac surgery day 10 presents with fever, chest pain, friction rub. Diagnosis and treatment?
✅ Answer: Postpericardiotomy syndrome. Aspirin or NSAIDs. Self-limited.
❓ Reflex prompt 3: A 14-year-old with pericarditis, echocardiogram shows large effusion, hypotension, JVD, muffled heart sounds. Next step?
✅ Answer: Cardiac tamponade → emergent pericardiocentesis. IV fluids while preparing.
❓ Reflex prompt 4: A 10-year-old with recurrent pericarditis (3 episodes) despite NSAIDs. Next step?
✅ Answer: Colchicine (reduces recurrence). If refractory, anakinra (IL-1 inhibitor) or low-dose corticosteroids.
❓ Reflex prompt 5: A 5-year-old with high fever, toxic appearance, large pericardial effusion. Next step?
✅ Answer: Purulent pericarditis. Emergent pericardiocentesis + IV antibiotics (vancomycin + ceftriaxone).
❓ Reflex prompt 6: A 15-year-old with pericarditis and elevated troponin (2 ng/mL), normal LV function. Diagnosis?
✅ Answer: Myopericarditis. Treat same as pericarditis. Monitor for myocarditis complications.
📌 Acute Pericarditis – Core Concepts (Nelson 22e, Chapter 489.1)

1. Definition: Inflammation of the pericardial sac. Most common etiology in children: viral (coxsackievirus, echovirus, adenovirus, influenza, EBV, CMV, COVID-19). Idiopathic, postpericardiotomy, autoimmune (SLE, JIA), uremic, bacterial (S. aureus, TB).
2. Clinical features: Chest pain (sharp, pleuritic, positional – worse supine, better leaning forward), pericardial friction rub (pathognomonic), fever.
3. ECG stages:
- Stage I: diffuse ST elevation (concave up) with PR depression.
- Stage II: normalization of ST/PR.
- Stage III: diffuse T-wave inversion.
- Stage IV: normalization.
4. Echocardiogram: Assess for pericardial effusion, signs of tamponade (RV collapse, IVC plethora, respiratory variation in Doppler). Normal LV function (differentiates from myocarditis).
5. Cardiac tamponade – Beck's triad: Hypotension, JVD, muffled heart sounds. Pulsus paradoxus >10 mmHg. Emergent pericardiocentesis.
6. Treatment – Acute pericarditis:
- First-line: NSAIDs (ibuprofen 30-50 mg/kg/day) for 1-2 weeks with taper.
- Colchicine for recurrent pericarditis (reduces recurrence by 50%).
- Corticosteroids avoided (risk of chronicity) except for autoimmune or severe refractory cases.
7. Postpericardiotomy syndrome: 1-6 weeks after cardiac surgery. Treat with aspirin/NSAIDs.
8. Purulent pericarditis: Toxic, febrile, tamponade. Emergent pericardiocentesis + IV antibiotics (vancomycin + ceftriaxone).
9. Recurrent pericarditis: Colchicine first-line. Refractory: anakinra (IL-1 receptor antagonist).
💡 Clinical pearls:
➤ Pericardial friction rub may be transient; listen with patient leaning forward, breath held in expiration.
➤ Differentiate pericarditis from myocarditis: myocarditis has elevated troponin, wall motion abnormalities on echo, LGE on MRI.
➤ Avoid NSAIDs in suspected TB pericarditis (may mask symptoms).
➤ Tamponade: pulsus paradoxus may be absent in LV dysfunction or ASD.
➤ Constrictive pericarditis is a rare long-term complication.