OVERVIEW

What is acute rheumatic pericarditis?

Rheumatic fever caused by group A streptococcal pharyngitis can invade the pericardium, primarily affecting the visceral layer of the pericardium, leading to serous or serofibrinous inflammation, resulting in acute rheumatic pericarditis. Patients may experience chest pain, and auscultation may reveal pericardial friction rub, distant heart sounds, or muffled heart sounds. Pericardial constriction or cardiac tamponade rarely occurs. Treatment includes eliminating streptococcal infection and alleviating pericarditis symptoms. Early treatment can lead to a cure, but delayed or inadequate anti-streptococcal therapy may result in chronic progression.

Is acute rheumatic pericarditis common?

The clinical incidence of rheumatic fever is relatively low, with a total incidence rate of less than 0.1% in China. It primarily affects children and young adults. Among rheumatic fever patients, 6%–12% develop acute rheumatic pericarditis.

Are acute rheumatic pericarditis and acute rheumatic carditis the same condition?

No, the latter includes the former. Acute rheumatic carditis can also involve the endocardium, myocardium, and valves, particularly the mitral and aortic valves.

Is acute rheumatic pericarditis hereditary?

No.

SYMPTOMS

What are the common clinical manifestations of acute rheumatic pericarditis?

Patients with acute rheumatic pericarditis may experience sudden sharp or stabbing pain behind the sternum or in the precordial region, which may radiate to the neck. They may also feel a sense of pressure in the chest that radiates to the left arm or shoulder. The pain may change with body position, worsening with inspiration or lying flat and slightly improving when sitting or leaning forward. Chest pain can last for hours or even days.

How does acute rheumatic pericarditis progress?

As pericardial effusion increases, symptoms of cardiac tamponade may develop, including pallor, cold and clammy extremities, tachycardia, abdominal distension, nausea, dyspnea, restlessness, confusion, or even shock.
During the recovery phase, the serous fluid is gradually absorbed, and most of the fibrin is dissolved and reabsorbed. However, partial organization may occur, leading to adhesions between the visceral and parietal layers of the pericardium, which may eventually result in constrictive pericarditis.

What complications may arise from acute rheumatic pericarditis?

When pericardial effusion increases, compression symptoms of adjacent organs may occur, such as:

• Lung compression may cause dyspnea or shortness of breath;
• Tracheal compression may lead to coughing;
• Recurrent laryngeal nerve compression may result in hoarseness;
• Esophageal compression may cause dysphagia.

Additionally, other symptoms of rheumatic fever may accompany the condition, such as fever, cough, arthritis, chorea, erythema marginatum, and subcutaneous nodules.

CAUSES

What are the causes of acute rheumatic pericarditis?

Rheumatic fever is caused by pharyngitis due to group A streptococcal infection, primarily through immune mechanisms, often occurring three weeks after infection. The M protein on streptococci has specific immune effects and anti-phagocytic properties, serving as the rheumatogenic factor of streptococci. Untreated streptococcal infections can easily lead to acute rheumatic pericarditis.

DIAGNOSIS

What tests are needed for acute rheumatic pericarditis?

• Laboratory tests:

• To monitor the progression of rheumatic fever, dynamic testing of inflammatory markers such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein is required;

• Electrolyte and liver/kidney function tests to assess internal environment and complications;

• Anti-streptolysin O (ASO) and anti-deoxyribonuclease B (anti-DNaseB) tests—80% of rheumatic fever patients test positive for ASO;

• Elevated myocardial injury markers (troponin, CK-MB, BNP, or NT-proBNP) can be used to evaluate the extent of cardiac damage and treatment outcomes;

• Etiological tests: Blood cultures to rule out other bacterial infections causing pericarditis, antinuclear antibody tests to exclude immune-mediated pericarditis, and tuberculin purified protein derivative skin tests to exclude tuberculous pericarditis.

• Electrocardiogram (ECG) and dynamic monitoring: Shows specific ST-T changes secondary to epicardial myocarditis.

• Throat swab culture: Only 25% of rheumatic fever patients test positive for pharyngeal secretions.

• Chest X-ray: In early acute pericarditis, the cardiac silhouette may appear normal. When pericardial fluid exceeds 250 ml, the silhouette enlarges. Large pericardial effusions may present as spherical or "water bottle" shapes, with weakened or absent cardiac pulsations visible under fluoroscopy.

• Echocardiography: Small pericardial effusions are visible only behind the ventricular wall during systole. Large effusions may cause diastolic collapse of the right ventricular anterior wall or localized left atrial collapse. 94% of rheumatic fever patients exhibit mitral valve prolapse, mitral annular dilation, and elongated chordae, requiring follow-up and dynamic monitoring.

• Pericardiocentesis and pericardial fluid analysis: Pericardial fluid smear, culture, biochemical, and pathological tests aid in etiological diagnosis.

• Other tests: Computed tomography (CT) or magnetic resonance imaging (MRI) may be performed if necessary to accurately determine the volume and location of effusions.

How to effectively diagnose acute rheumatic pericarditis?

• History of Group A streptococcal infection, with clinical manifestations such as fever, cough, sputum, chest pain, arthritis, or chorea. Physical examination may reveal pericardial friction rub, erythema marginatum, or subcutaneous nodules.

• Typical ECG ST-T changes.

• Echocardiography shows pericardial effusion (hypoechoic areas), mitral valve prolapse, annular dilation, or elongated chordae.

• Laboratory tests show elevated inflammatory markers, positive ASO and anti-DNaseB, and positive throat swab, blood culture, or pericardial fluid culture.

What diseases should acute rheumatic pericarditis be differentiated from?

• Acute myocardial infarction: May present with chest tightness, pain, and dyspnea, with significantly elevated myocardial markers. Coronary angiography can differentiate—coronary artery disease patients show localized myocardial motion abnormalities on echocardiography. Acute rheumatic pericarditis shows negative coronary angiography and no localized myocardial hypokinesis.

• Non-rheumatic pericarditis: Includes infectious, autoimmune, metabolic, neoplastic, drug-induced, or traumatic acute pericarditis. Differentiation relies on medical history, laboratory tests, medication history, tumor history, and etiological evidence.

• Severe pneumonia: Severe pneumonia with septic shock may also cause chest tightness and transient mild elevation of myocardial markers, but symptoms improve significantly with shock resolution and oxygen saturation correction. Acute rheumatic pericarditis does not improve without pericardial effusion drainage.

• Stress cardiomyopathy (Takotsubo syndrome): Also called apical ballooning syndrome, it predominantly affects postmenopausal women, often triggered by intense emotional stress. Symptoms include chest pain, elevated myocardial markers, and ECG changes. Left ventriculography shows characteristic apical wall motion abnormalities resembling an octopus trap. Left ventricular function recovers quickly, often requiring only supportive treatment. Acute rheumatic pericarditis lacks significant emotional stress history and does not show left ventricular angiographic changes.

TREATMENT

Which department should I visit for acute rheumatic pericarditis?

Visit the cardiology department at your local hospital.

How should acute rheumatic pericarditis be treated?

Early treatment for the underlying rheumatic disease is required, including eliminating streptococcal infection and relieving pericarditis symptoms.

• General treatment: Hospitalization for close observation and treatment, bed rest for at least 8–12 weeks.

• Anti-rheumatic therapy: Aspirin 4–6 g daily, divided into 3–4 oral doses. Reduce the dose if tinnitus, nausea, or vomiting occurs. If salicylate preparations are ineffective, corticosteroids may be tried. The initial dose should be high, such as prednisone 30–40 mg daily for adults, divided into 3–4 oral doses. After 3–6 weeks, the dose can be gradually reduced, with a usual maintenance dose of 10–15 mg daily for a total course of 12 weeks. The specific dosage should follow the doctor's prescription.

• Antibiotic therapy: Penicillin is the first-choice antibiotic, with a common dosage of 1.6–3.2 million units daily, divided into two intramuscular injections, for a course of 10–14 days. Afterward, long-acting penicillin (1.2 million units) is administered every three weeks. For those allergic to penicillin, erythromycin (1.5 g daily, divided into three oral doses) can be used for 10–14 days.

• Symptomatic treatment: For severe chest pain, codeine (15–30 mg orally), morphine (5–10 mg), or pethidine (50–100 mg intramuscularly) may be used. If cardiac tamponade occurs, immediate pericardiocentesis and drainage are necessary.

Can acute rheumatic pericarditis be cured?

It is curable, but without timely anti-streptococcal treatment, it may become chronic. Long-term follow-up is required after symptom relief, including blood tests, electrocardiograms, and cardiac ultrasounds.

DIET & LIFESTYLE

What should patients with acute rheumatic pericarditis pay attention to in daily life?

• Maintain personal hygiene and clean living environment, avoid crowded public places, wear masks to prevent upper respiratory infections;

• Reduce stress, get adequate rest, and enhance the body's natural defense capabilities;

• Supplement nutrition such as vitamin C, β-carotene (vitamin A), and zinc;

• Actively participate in physical exercise to improve disease resistance. With age, the likelihood of recurrent rheumatic fever decreases, and the intervals between episodes lengthen.

PREVENTION

Can acute rheumatic pericarditis be prevented? How to prevent it?

Stress, overwork, exhaustion, and viral infections may weaken the body's defense mechanisms, making it more susceptible to streptococcal pharyngitis. Like other throat infections, strep throat tends to occur during colder months.
The best way to avoid streptococcal infection is to reduce stress, get adequate rest, enhance the body's natural defenses, and supplement nutrients such as vitamin C, β-carotene (vitamin A), and zinc.

How to prevent recurrence of acute rheumatic pericarditis?

Recurrent episodes of rheumatic pericarditis are caused by repeated streptococcal pharyngitis infections (Group A Streptococcus). Continuous prophylactic antibiotic use is a relatively effective measure to prevent recurrence. Patients with confirmed rheumatic fever should start antibiotic treatment as early as possible.