Rheumatic pericarditis, symptoms

July 10, 2018 01:30 | Disease Treatment
Rheumatic pericarditis does not occur alone, by itself, but always accompanied by endomyocarditis. Involving the pericardium in the process has a decisive influence on the fate of the child. Prior to the use of cortisone and ACTH, a significant proportion of patients with pericarditis had very rapid onset of circulatory failure, and those suffering from this form of the disease very rarely managed to save themselves from fatal consequences. Looking at the 5-year sectional material of our clinic, it turned out that only children who suffered from pericarditis also died from rheumatic fever. The pancarditis coming in the first phase of rheumatic fever was already not as severe as during the application of old methods of treatment, as in those cases when the pericardium was affected during the second or third diffusion, because the capacity of the already infected at the first attacks of the myocardium with inflammation of the pericardium decreases very significantly. The prognosis with limited inflammation is more favorable. However, this form of manifestation is rarely observed, and in a significant part of cases the diffuse change covers both the parietal and visceral pericardial sheets. Since the introduction of cortisone treatment, we have not lost a single patient whose pancarditis appeared as the first disease, and only children died whose pancarditis repeatedly recurred. Inflammation is serous and fibrinous in nature. On the leaves of the pericardium there are abundant fibrous deposits: cor villosum. A significant accumulation of fluid is also found in rheumatic pericarditis, but rarely. If the treatment is unsatisfactory, if the patient survives after the acute stage, the consequences of scarring the pericardium are severe. A significant number of patients die for a more or less prolonged time from decompensation. It has not yet been fully explained why even a seemingly insignificant pericarditis suddenly and so significantly worsens the general condition of the patient and the performance of the heart. Our own clinical observations indicate that the serious condition of these patients is likely a consequence of the compression of the coronary veins and lymphatic vessels.

This is our view is also confirmed by the experimental studies of Földi and his collaborators. Especially severe clinical picture occurs when the inflammation passes to the mediastinum. The fate of such patients - suffering from pericarditis - in our experience - is predetermined.

Symptoms of .Regardless of whether the cardiac manifestation of rheumatic fever begins immediately with pancarditis or whether it joins a pre-existing carditis, the patient's condition - both objective and subjective - is so clearly difficult that it already causes suspicion of pericardial inflammation. Lethargy, pallor, anxious eyes, intermittent breathing, inadequate degree of decompensation, lack of movement, complete loss of appetite occur with only one endomyocarditis very rarely, and for pancarditis they are characteristic. The child sometimes lies motionless, in other cases, bending forward, on the edge of the bed puts his head in his hands or leans on his knees, pulled up to his chest.

In the vast majority of cases, pericarditis is accompanied by a characteristic noise. Especially in the beginning, the friction between the pericardial sheets resulting from the imposition of fibrin causes a systolic-diastolic friction noise. Noise follows the individual phases of cardiac work, and accordingly it is two- or three-phase. Noise is first heard on the left side of the sternum in the II-III intercostal space, corresponding to the inflection point, the pericardial fold located above the large vessels. This area of ​​auscultation is also projected as the phase of expulsion of conus pulmonalis and right ventricle located directly under the chest wall. Probably the possibility of removing two leaves of the pericardium from each other here is the smallest. Later, the noise becomes audible over the entire atrial area, and it disappears only if the process is cured or if the pericardial sheets separate from each other by a large accumulation of fluid. For friction noise, it is characteristic that it increases when the phonendoscope is pressed against the chest wall.

Cardiac dullness has a characteristic form even with a relatively small accumulation of fluid. The accumulation of fluid in several ml( 15-20 ml) is enough to fill the angle between the heart and the diaphragm on the right and on the left sides, giving the stupidity of the heart a characteristic triangular shape, located at the base of the pericardial sac. When assessing dullness in the right-hand corner of the diaphragm and the atrium, small children need to be very careful, because through a thin chest, it is possible that swollen glands in the right gill can be percussed and cause suspicion of fluid accumulation. On the back on the left side, above the diaphragm, in the interscapular space, there is dullness, bronchial breathing is often heard above it. Mistakenly, it is possible to diagnose pneumonia, but in fact it is a matter of squeezing the lungs, caused by the accumulation of fluid. In the case of fluid accumulation in the pericardium, the apical impulse is usually located within the left border of dullness. With the increase in fluid accumulation, the shape and magnitude of the dullness of the heart changes, the apical impulse may appear to be worn out or even disappear altogether. With a large amount of fluid above the dullness of the heart, sometimes when you move, you can hear the splash.

With pericarditis, a characteristic symptom is a tachycardia that does not respond to digitalis or strophanthin. In its early form, it under the influence of cortisone, so to speak, improves in 24 hours or returns to almost normal values.

Pericarditis is often accompanied by pain in the heart, a feeling of tightness and pressure. If the inflammation also spreads to the diaphragm part of the pericardium, the stitching pain appears in the abdomen, which can lead to diagnostic errors( for example, appendicitis).Inflammation can also go to the liver capsule, and in such cases, acute pain is caused jointly by perihepatitis and usually a rapidly developing congestive enlargement of the liver. Pericarditis and perihepatitis may be associated with peritonitis and perisplenitis. The clinical picture of pericarditis can be complicated by the onset of mediastinal pleurisy. For the pericardium, the "hamster cheek", the swelling of the cheeks, is characteristic. This symptom - unfortunately - almost in all cases is a symptom of a fatal outcome.

When X-ray examination, a large accumulation of fluid can give a shadow of the heart the shape of the bottle: along with the upper, narrow neck part, the lower part of the pericardium gradually expands, the contours of the heart can not be examined in detail. Contours of the heart, even with fibrinous form, accompanied by a small accumulation of fluid, erased, pulsation consists of very small waves. It is often difficult to differentiate this clinical picture from acute cardiac enlargement. Filling the angle between the heart and the diaphragm when shooting in the sagittal and oblique directions indicates pericarditis. Differentiation of the pericardial fluid accumulation from the bovine heart is facilitated by three symptoms: 1. pulsation in small waves.2. the triangular or shadow of the heart that merges with the diaphragm and closes the contours of the heart, 3. the normal course of the bronchi( with the bullish heart the left main bronchus is raised by the enlarged left atrium).

The presence or absence of stagnation in a small circle of circulation with acute pericarditis has no diagnostic value. Stagnation depends on the conditions of heart filling and on the degree of reduction of strength in the two halves of the heart.

An electrocardiogram clearly indicates the existence of pericarditis if, at the earliest stage in two or all three leads from the extremities, the segment ST in one direction is elevated, the S-wave is well pronounced and the T-wave is still positive. After 2-6 weeks, the growth of the segment ST slowly disappears, the T teeth become low positive or isoelectric and then become negative, resembling a negative T wave, characteristic of blockage of the coronary vessels. During treatment, the T teeth become again isoelectric or positive. This behavior of the segment ST, considered to be characteristic, we observed only in about one third of cases, however, after this second week, we did not always find the inversion of the T wave. According to our observations, in rheumatic pericarditis, the T teeth usually become only low positive or isoelectric. The segment of QT in the acute period is usually shorter than it would be expected in comparison with the frequency of cardiac activity. With pericarditis of another etiology( for example, with tuberculous pericarditis), lower deviations are also observed. However, with rheumatic pericardial depression of the voltage is very rare. Low deviations are due not to the accumulation of fluid, but to the disease of the myocardium.

With acute and subacute pericardial, i.e. in an early stage, the balance of the circulation is very easily disturbed if timely and appropriate therapy is not performed. The treatment of such decompensation is not a gratifying task, because the existing adhesions and the usually occurring defects at this time - together practically make the heart work not satisfactory. Thus, it is desirable that the patient may have got into the hospital earlier, where the use of modern therapy in recent years already manages to prevent the fatal consequences of this disease. Those patients who come to us with heart lesions that have arisen in connection with the dissipation that took place before, we can hardly help. In these cases, even the correct treatment of an acute process does not solve the problem of old scarring. Such patients usually die within 1-2 years.

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