SLE - fibrinous or serous pericarditis

Discussion in 'Step I' started by Phloston, Aug 17, 2012.

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  1. Phloston

    Phloston Lifetime Donor 5+ Year Member

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    P. 302 of FA2012 says serous pericarditis for SLE, but Kaplan QBank specifically says fibrinous.

    In terms of the USMLE, which one is it?
     
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  3. Myxedema

    Myxedema 2+ Year Member

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    Both serous and fibrinous type of pericarditis can be seen in SLE.

    "Pericardial Disease", Robbins Pathologic Basis of Disease, 8E:

    and

     
  4. Phloston

    Phloston Lifetime Donor 5+ Year Member

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    Thanks, myxedema. Hopefully this means other information would be given in the vignette to be able to infer which type, if they ask on the actual exam.
     
  5. MrBeauregard

    MrBeauregard Soon-to-be PGY-1 5+ Year Member

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    That seems like a difficult clinical distinction.

    From what I remember during my studies, you're less likely to encounter a question that describes a patient with SLE, pericarditis, and an effusion that asks for the type of pericarditis than you are to see a question describing a young patient with chest pain relieved by leaning forward, a friction rub on auscultation that persists through the patient holding their breath, and then asks for the diagnosis.

    I'd be interested to hear from someone who knows how to, if possible, make a clinical distinction between the two.
     
  6. Myxedema

    Myxedema 2+ Year Member

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    Pericarditis: Inflammation of pericardium.

    Symptoms: Chest pain (aggravated by movement of trunk, inspiration, coughing [i.e. pleuritic]; relieved by sitting up [i.e. positional]); fever, malaise, etc. As you can see, these symptoms are not so different from any other inflammatory condition of the body (e.g. pneumonia: chest pain, fever, malaise, etc.; osteomyelitis: bone pain, fever, tachycardia, etc.). This type of pain is different from the ischemic type of pain seen in MI.

    Physical examination: Pericardial friction rub may be heard

    EKG: Concave ST elevation in all ventricular leads with accompanying PR segment depression.

    CXR: May be normal; pleural effusion can be seen if large enough.

    Echo: May be normal if accompanying percardial effusion is small enough. If enough effusion is present and the etiology is not clear, pericardiocentesis may be performed for lab. analysis and culture.

    Pericardial effusion: Response of pericardium to inflammation. It may be range from little (barely detectable by echocardiography) to large amounts of effusion detectable by chest X-ray.

    The feared complication of pericardial effusion is cardiac tamponade. If the effusion occurs fast enough, even with small amounts of effusion, the pericardial sac would not be able to distend fast enough. As a result, the amount of blood entering the heart will be restricted.

    Clinical: Beck's triad is typical of tamponade: (1) Elevated JVP, (2) Arterial hypotension, and (3) Quiet heart sounds. Pulsus paradoxus (>10 mm Hg drop in blood pressure during inspiration) is specific for tamponade.

    EKG: Electrical alternans (Alternating height of QRS complex with each beat)

    Echo: Shows the large effusion with tamponade

    ---

    Patient presents with sharp, retrosternal pain, which is aggrevated by inspiration and relieved by sitting up. During physical examination, friction rub is heard. EKG shows widespread ST segment elevation with PR depression. CXR shows left pleural effusion. Echo shows minimum to moderate amount of pericardial effusion --> Acute pericarditis

    Patient presents with dull chest pain. Cardiac auscultation reveals distant, muffled heart sounds. Physical examination reveals elevated JVP and hypotension with tachycardia. 15 mm Hg drop in blood pressure is observed during inspiration. EKG shows electrical alternans. Emergency echocardiography with pericardiocentesis is performed. --> Cardiac tamponade
     
  7. MrBeauregard

    MrBeauregard Soon-to-be PGY-1 5+ Year Member

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    Got that.

    How about serous vs. fibrinous? Both are a form of pericarditis, so everything you mentioned at first will be present in both. Fibrinous can be associated with an effusion, and, well, serous obviously can, too. So, everything you mentioned in the second portion may also be present.

    If I understood Phloston's question, how can we differentiate them from one another?
     
  8. Myxedema

    Myxedema 2+ Year Member

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    I've already mentioned it in the Echo heading of pericarditis. If the diagnosis cannot be clinically made (i.e. patient with breast cancer presents with pericarditis), pericardiocentesis may be performed. Lab. analysis and culture of that aspirate will guide the diagnosis. (Think about CSF analysis and culture)

    Clinically, determining the etiology (if necessary), is more important than determining the type of effusion, since that will guide the rest of the treatment. A Step I level question may give you the laboratory results of a pericardial aspirate (protein content, glucose content, urea, presence of WBCs/RBCs, Gram staining, etc.) and ask a possible etiology. For example:

    A 60-year-old man with a history of long standing hypertension and diabetes presents to the ED with an acute onset of retrosternal, sharp chest pain. Physical examination reveals that his chest pain was aggravated with inspiration and relieved by sitting forward. Moderate pleural effusion is present in echocardiography. Analysis of the pericardial effusion shows low levels of protein with negative Gram stain. His blood biochemistry shows elevated BUN and Cr. Levels of which substance is most likely to be elevated in the pericardial effusion aspirate?
     
  9. Phloston

    Phloston Lifetime Donor 5+ Year Member

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    I've actually had a Kaplan QBook question that asked about the type of pericarditis following an MI. Both immediately after and weeks later (Dressler's) are fibrinous.

    I've seen in practice questions that exudates must have effusion protein and LDH greater than 0.5 and 0.6 that of serum values.

    I've also seen that effusions secondary to pulmonary embolus are exudative, not transudative.

    If I got the serous vs fibrinous question on the USMLE, I would just hope that they gave additional information in the vignette to support one over the other.

    And I just thought I should mention that when I search in Google now, the only thing that comes up is multiple copies of this thread!
     
  10. Boardz

    Boardz

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    serous>>>>>>>fibrinous.

    all day.
     
  11. chronicidal

    chronicidal Scrub 5+ Year Member

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    If I understand this thread correctly, Kaplan is full of crap and the distinction between fibrinous and serous is clinically meaningless. Who's with me?
     

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