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CLINICAL MANIFESTATIONS

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Precordial chest pain is the most common symptom of pericarditis. It is often unrecognized in young children, in whom the manifestations are irritability and a grunting expiratory sound as they splint the thoracic cage. Exercise intolerance and fever are common but nonspecific manifestations of pericardial infection. Enteroviral infection is often characterized by fever, malaise, and a rash, while bacterial pericarditis frequently follows an upper respiratory tract infection. Thus fever, weakness, and chest pain after nonspecific febrile or upper respiratory tract illnesses should suggest consideration of the diagnosis of pericarditis.
Pain is felt over the entire precordium, to the left side over the trapezius ridge, and over the scapula; it sometimes radiates down the arm and can be aggravated by movement. Pain may also be referred, because pericardial pain fibers are located in the diaphragmatic reflection of the pericardium. Pain is more common in acute infectious pericarditis than in more indolent forms.
Examination of the heart may reveal muffled heart sounds caused by the surrounding effusion and increasing tachycardia as the effusion impinges on the volume of chambers. A pericardial friction rub may be audible, especially when the effusion is small. The rub is heard best during deep inspiration and with the patient kneeling or in the knee-chest position, leaning forward. It is typically a to-and-fro, high-pitched loud crackle, heard throughout the cardiac cycle, although it can be limited to systole.
Clinical manifestations of tamponade include tachycardia, peripheral vasoconstriction, reduced arterial pulse pressure, and pulsus paradoxus. Pulsus paradoxus represents a drop of >10 mm Hg in systolic blood pressure during inspiration due to decreased venous return to the heart. Pulsus paradoxus is not pathognomonic for pericardial tamponade; it can be seen in the presence of chronic lung disease and in pericarditis without tamponade.

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