Definition
These are repeated episodes of inflammation of the pericardium, the membrane that surrounds and protects the heart. Recurrent pericarditis is diagnosed when a new flare occurs at least 4 to 6 weeks without symptoms after the initial episode.
Why can flares return?
In most cases, no specific cause is found: this is referred to as an idiopathic form.
During the first episode, a viral infection is often identified.
Much more rarely, it may be part of an immuno-inflammatory disease (such as lupus, Still’s disease, Familial Mediterranean Fever) or occur after surgery.
Epidemiology
It affects patients in all countries worldwide.
This is a rare disease.
The risk of recurrence after an acute pericarditis episode is estimated to be 20 to 30%, and 5 to 10% of patients may experience multiple recurrences.
It typically affects young or middle-aged individuals, with no sex predominance.
Etiology:
The main causes of recurrent pericarditis are:
1. Infections:
Viral: such as coxsackievirus infections, herpes, HIV, or other viruses.
Bacterial: especially tuberculosis.
Fungal or parasitic infections: rarer and mostly seen in immunocompromised individuals.
2. Diseases:
Autoimmune diseases: such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, or Sjögren’s syndrome.
Autoinflammatory diseases: such as Familial Mediterranean Fever or Still’s disease.
3. Trauma or surgery:
Chest trauma or thoracic/cardiac surgery can lead to acute pericarditis, which may then evolve into recurrent episodes.
4. Certain cancers:
Such as lung cancer, breast cancer, or lymphomas.
5. Idiopathic cases:
When no cause is found, the pericarditis is considered idiopathic (most common situation).
Clinical
Patients experience acute chest pain behind the sternum, worsened by deep inspiration, along with fever and sometimes chest tightness and shortness of breath.
Diagnostic
The diagnosis of recurrent pericarditis is based on:
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The presence of chest pain with or without fever.
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Evidence of blood inflammation shown by blood tests, mainly C-reactive protein (CRP). An elevated CRP level is important to confirm a recurrence.
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Evidence of a pericardial effusion (increased pericardial fluid) on echocardiography, CT scan, or cardiac MRI.
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In rare cases, pericardial fluid drainage (pericardiocentesis) or pericardial biopsy may be performed to confirm the diagnosis and look for specific causes, especially if an inflammatory or infectious disease is suspected.
If CRP does not increase, the situation should be discussed with a specialist, as it may differ from typical recurrent pericarditis.
Treatment
Treatment aims to relieve pain, treat the underlying disease, and prevent recurrences.
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First-line treatment:
Non-steroidal anti-inflammatory drugs (NSAIDs) (such as aspirin or ibuprofen) combined with colchicine
– for 3 months in a first episode
– for at least 6 months in case of recurrence.
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Second-line treatment:
Biologic therapy targeting interleukin-1 (anakinra) for severe or resistant forms. These treatments are prescribed in expert centers.
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Corticosteroids:
Rarely used, except in specific conditions (such as lupus), because they may increase the risk of recurrence.
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Treatment of the underlying cause:
Should not be overlooked when identified.
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Drainage of the pericardial effusion:
Reserved for cases where a large amount of fluid accumulates around the heart and interferes with its function.
What to do on a daily basis?
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Follow the treatment without stopping it abruptly.
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Have the recommended blood tests done (especially CRP).
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Gradually resume your activities.
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Avoid sports until the pain or inflammation has disappeared.
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Do not hesitate to consult a doctor in case of unusual pain or fever.
Can I play sports?
It is recommended to stop sports until symptoms have completely disappeared, CRP levels have returned to normal, and the ultrasound check is reassuring. After that, sports can be resumed progressively.
Special cases
In children: highly inflammatory forms should prompt a search for an autoinflammatory disease.
In pregnant women: colchicine is permitted; some other treatments are not.
If flare-ups are frequent: consulting a specialized expert center is helpful.