Viral genomes in the pericardial fluid and in peri- and epicardial biopsies from a German cohort of patients with large to moderate pericardial effusions

Abstract

The aetiology of pericardial effusion has been generally assessed by clinical work-up only, which leaves a large cohort of patients with "idiopathic" effusions virtually undiagnosed. In accordance with the ESC guidelines, this contribution intends to change this attitude. After therapeutic or diagnostic pericardiocentesis of 259 patients with large to moderate pericardial effusions, pericardial fluid, epicardial and pericardial biopsies, and blood samples were analysed by PCR for cardiotropic microbial agents. Cytology, histology, immunohistology of tissue and fluids and laboratory tests were performed. Of the 259 patients, 35 % suffered from an autoreactive aetiology, 28 % suffered from a malignant and 14 % from an infectious cause. Investigating all samples by PCR, we identified viral genomes in 51 (19.7 %) patients, parvovirus B19 (B19 V) being identified in 25 and Epstein-Barr virus (EBV) in 19 cases. In patients with a sole infectious aetiology (n = 36), B19 V was detected in 21 and EBV in 10 cases. When differentiating with regard to the material investigated for the presence of cardiotropic viruses, parvovirus B19 was most often detected in the epicardium and EBV was most frequently detected in the pericardial fluid independent from the final diagnostic categorisation. Bacterial cultures including tests for tuberculosis were all negative. Molecular techniques improve sensitivity, specificity and diagnostic accuracy for the underlying aetiology in pericarditis patients with effusion. The identification of specific viral signatures will help to understand pathogenetic mechanisms in pericarditis and allow to tailor an adequate therapy beyond antiphlogistic treatment.

Clinical Profile and Influences on Outcomes in Patients Hospitalized for Acute Pericarditis

“…The cause of acute pericarditis is idiopathic in the majority of cases but includes an immune-mediated process that is probably triggered by a viral infection in many cases. 16,17 Reasons for sex differences in pericardial inflammation are unknown, but experimental viral studies of myocardial inflammation have suggested that although genetic differences have some effect, sex hormones are major contributors for sex predisposition. 3, 18 Testosterone appears to play a major role in the development of myocarditis, because exogenous testosterone increases viral replication and inflammation in the heart and gonadectomy inhibits cardiac inflammation in experimental viral myocarditis.…”

Echo-guided pericardiocentesis in patients with clinically significant pericardial effusion

“…The most common etiology was idiopathic in the studies of Sagristà-Sauleda et al [9] and Levy et al [10] (29% and 48%, respectively); and in the study of Corey et al [11] it was infectious causes (27%) including unusual agents such as M. pneumonia and M. avium-intracellulare. Of note, in a recent prospective registry of 259 patients, an autoreactive etiology was the leading diagnosis in 35%, followed by malignancy in 28%, and viral etiology in 14% of the cases [12]. These discrepancies seem to mainly result from how aggressively the etiologic investigation was carried out.…”

“…This is most relevant for autoreactive pericarditis. Since PCR for the identification of cardiotropic viruses in pericardial fluid was not carried out in the present study, these patients might have constituted part of the patients with idiopathic pericarditis [12,19]. In addition, analysis of tumor markers (CEA, CA 19-9 etc.)…”

2015 ESC Guidelines for the diagnosis and management of pericardial diseases

“…Przyczyną nawrotów w wielu przypadkach jest niewłaściwe leczenie pierwszego epizodu zapalenia osierdzia. U nawet 20% chorych po wykonaniu dodatkowych badań w materiale z płynu osierdziowego lub z samej tkanki oserdzia stwierdza się etiologię wirusową schorzenia [63].…”

“…Zabiegi inwazyjne [206] umożliwiają wykonanie badania obrazowego (perikardioskopia) i uzyskanie materiału do badań molekularnych, histologicznych i immunohistochemicznych w celu identyfikacji czynnika etiologicznego oraz Poziom wiarygodności danych ustalenia mechanizmów patogennetycznych uszkodzenia osiedzia i nasierdzia [133]. W ten sposób możliwe jest też wykonanie procedury leczniczej, z podaniem leków do worka osierdziowego [63,204].…”