1Case Report Post Op Pericardial Effusion ec RHDPresenter: Ramos (100100125)Dina Utami (10010010)!uper"isor : dr# $u%ammad &li' !p#& (()INTRODUCTION&cuter%eumaticfe"er (&R))isanauto*immuneconse+uenceofinfection,it%t%e-acterium .roup & streptococcus (/&!)# 0t causes an acute .eneralised in1ammator2response and an illness t%at aects onl2 certain parts of t%e -od2 3 mainl2 t%e %eart'4oints' -rain and s5in# 0ndi"iduals ,it% &R) are often se"erel2 un,ell' in .reat pain'andre+uire%ospitalisation# Despitet%edramaticnatureof t%eacuteepisode' &R)lea"es no lastin. dama.e to t%e -rain' 4oints or s5in# &cute r%eumatic fe"er (&R)) is anillness caused-2areactiontoa-acterial infection' ,%ic%oftenresults inlastin.dama.e to %eart "al"es# 6%is is 5no,n as r%eumatic %eart disease (RHD) and it is animportant cause of premature mortalit2# &lmost all cases of RHD and associated deat%sare pre"enta-le# Ho,e"er' &R) and RHDremain common in man2 de"elopin.countries# RHD is t%e most fre+uent form of %eart disease in c%ildren ,orld,ide#1&cuter%eumaticfe"erisanon*suppurati"ecomplicationof.roup & -eta%emol2ticstreptococcal (/&7H!) sore t%roat# 0t affects 4oints' s5in' su-cutaneous tissue' -rainand %eart# E8cept %eart' all ot%er effects are re"ersi-le' needin. onl2 s2mptomatic reliefdurin.t%eepisodes# Cardiaccomplications aresi.nificant ina-senceof secondar2prop%2la8is and culminate into c%ronic and life t%reatenin. "al"ular %eart disease# 26%e onl2 cost*effecti"e approac% to controllin. RHD is secondar2 prop%2la8is in t%eform of penicillin in4ections e"er2 9:; ,ee5s to pre"ent recurrent attac5s of .roup &streptococcal infection t%at cause &R) and' t%us' t%e ,orsenin. of RHD#Ho,e"er' t%ema4orit2of patients ,%oenroll intore.ister*-asedpro.rams ares2mptomatic,it%ad"anced disease' indicatin. t%at t%e2 %a"e %ad a num-er of silent or undetected attac5sof &R)# Patients ,it% mild' as2mptomatic RHD %a"e t%e most to .ain from second* ar2prop%2la8is -ecause' int%ea-senceof &R)recurrence' t%ema4orit2,ill %a"eno2detecta-le disease ,it%in 5:10 2ears# !creenin. to detect as2mptomatic cases is't%erefore' an attracti"e strate.2# 96raditionall2' RHD ,as dia.nosed -2 auscultatin. for a %eart murmur in t%ose ,it% a%istor2of &R)# Until t%e past decade' t%e stet%oscope ,as t%e onl2nonin"asi"edia.nostic tool a"aila-le to p%2sicians in lo,*income countries and in remote settin.s,%ere &R) and RHD are most pre"alent# Ho,e"er' detection rates ,ere usuall2 lo,#Ec%ocardio.rap%2 %as pro"en to -e more sensiti"e and specific t%an auscultation# RHDdetectedonec%ocardio.rap%2,it%out anassociatedclinicall2pat%olo.ical cardiacmurmurisreferredtoasit%t%ead"ent ofporta-letec%nolo.2'ec%ocardio.rap%2canno,-eperformedat arelati"el2lo,cost' e"eninremotesettin.s# 6%is de"elopment raises t%e possi-ilit2 t%at people ,it% pre"iousl2undia.nosed RHD' includin. t%ose ,it%out a 5no,n %istor2 of &R)' can -e dia.nosedandsecondar2prop%2la8is startedat anearlier sta.eof t%eillnesst%anpre"iousl2possi-le' t%us potentiall2 reducin. mor-idit2 and mortalit2#9ETIOLOGYR%eumatic fe"er results from an inflammator2 reaction to certain .roup & streptococcus-acteria# 6%e -od2 produces anti-odies to fi.%t t%e -acteria' -ut instead t%e anti-odiesattac5 a different tar.et: t%e -od2?s o,n tissues# 6%e anti-odies -e.in ,it% t%e 4oints andoften mo"e on to t%e %eart and surroundin. tissues# 7ecause onl2 a small fraction (fe,ert%an 0#9@) of people ,it% strep t%roat e"er contract r%eumatic fe"er' medical e8pertssa2 t%at ot%er factors' suc% as a ,ea5ened immune s2stem' must also -e in"ol"ed in t%ede"elopment of t%e disease#;PATHOGENESIS0nteractions in"ol"in. streptococci and t%e %ost pla2 an essential pat%o.enetic role forR) occurrence# Of t%e A*%emol2tic streptococci t%at can produce infection in %umans'onl2 t%ose -elon.in. to .roup & can lead to R)' almost e8clusi"el2 after tonsillitis orp%arin.itis# One of t%e first mec%anism proposed to e8plain in4ur2 in R) ,as a direct in*"asion of t%e affected tissue -2 t%e !treptococcus# E"idence of a latenc2 period of a-out9 ,ee5s -et,een t%e acute streptococcal in* fection and t%e clinical appearance of tissuein4ur2 su..ests t%at tissue dama.e is mediated -2 an immunolo.ical reaction ,it% an3autoimmune component# (aplanand%is co,or5ers %a"e proposedt%e concept ofBanti.enicmimicr2C: anti-odies produced-2t%estreptococcal infectiona.ainst t%e-acterial anti.ens cross*react ,it% t%e %ost tissues leadin. to tissue in4ur2# 6%edescription of t%e immunolo.ic cross*reacti"it2 -et,een t%e $ protein and m2ocardialsarcolemma lends support to t%is concept# &fter t%e immune reaction t%ere is asu-se+uent inflammator2process in"ol"in.m2ocardiumand"al"ular endocardium#>it%pro.ressionandpersis*tenceofinflammation "al"e fi-rosis andcal* cificationmi.%t occur# 0t is e8timated t%at onl2 0#9@of indi"iduals ,it% an untreatedstreptococcalp%ar2n.itis,illpresentanepisodeofR)#$oreo"erR)incidencefol*lo,in. p%ar2n.itis in patients ,%o %a"e %ad a pre"ious episode of R) is appro8imatel250@# 6%is o-ser"ation' to.et%er ,it% clinical studies indicatin. a familiar clusterin. oft%e disease' su..ests t%at .enetic factors mi.%t pla2 a role in t%e suscepti-ilit2 to R)# 0t%as -een reported t%e presence of specific 7*cell alloanti.en in t%e DD@ of patients ,it%R) and in onl2 1;@ of controls# /enetic suscepti-ilit2 to R) is also supported -2 t%eassocia* tion ,it% HE&*DR2 and DR; anti.ens# 56%e pat%o.enesis of r%eumatic %eart disease results froman immune responseconsistin. of %umoral and cellular components after e8posure to !treptococcusp2o.enes (classified as a .roup & streptococcus -2 t%e Eancefield s2stem)' usuall2 aftera t%roat infection# 6%e precise pat%op%2siolo.2 is o-scure -ut se"eral ad"ances %a"eno, -een re"ie,ed# &nti.enic mimicr2 in association ,it% an a-normal %ost immuneresponseist%ecornerstoneofpat%op%2siolo.2'-asedont%etriadofr%eumato.enic.roup & streptococcal strain' .eneticall2suscepti-le%ost' anda-errant %ost immuneresponse#5!ome strains are more li5el2 to cause acute r%eumatic fe"er t%an are ot%ers# ! p2o.enescontains $' 6' and R surface proteins' ,%ic% are all associated ,it% -acterial ad%erencetot%roat epit%elial cells# 6%er%eumato.enicit2of somestreptococcus families %astraditionall2-eenconsideredafeatureofstrains-elon.in.tospecific# $serot2pes#Ho,e"er' data s%o, t%at r%eumato.enic $ serot2pes ,ere infre+uentl2 identifi ed incommunities ,it% %i.% -urdens of acute r%eumatic fe"er and r%eumatic %eart disease#6%eseresults+uestiont%epotential importanceofot%er diseasecausin.serot2pes'especiall2 t%ose t%at cause streptococcal s5in infections' ,%ic% mi.%t -e implicated incases of acute r%eumatic fe"er# 0n 1FFD' C%eadle noted t%at t%e c%ance of an indi"idual4,it% a famil2 %istor2 of acute r%eumatic fe"er ac+uirin. t%e disease is Bnearl2 fi"e timesas .reat as t%at of an indi"idual ,%o %as no suc% %ereditar2 taintC#/enerall2' HE& class00 molecules (,%ic% participate in anti.en presentation to 6*cell receptors) seem to -emore closel2 associated ,it% an increased ris5 of acute r%eumatic fe"er or r%eumatic%eart disease t%an are class 0 molecules' alt%ou.% no sin.le HE&%aplot2pe orcom-ination%as -eenconsistentl2associated,it%diseasesuscepti-ilit2# 6%ee8actmolecular mec%anism-2 ,%ic% HE&class 00 molecules confer suscepti-ilit2 toautoimmune diseases is un5no,n# 6%e role of autoimmune reactions in t%e pat%o.enesisof acute r%eumatic fe"er ,as su-stantiated ,%en anti-odies a.ainst .roup &streptococcus reacted ,it% %uman %eart preparations#&fter -indin.tot%e anti.enic peptide' t%e particular HE&comple8es caninitiateinappropriate 6*cell acti"ation# $olecular mimicr2 ta5es place -et,een streptococcal $protein and se"eral cardiac proteins (cardiac m2osin' tropom2osin' 5eratin' laminin' and"imentin)' and different patterns of 6*cell anti.en cross*reco.nition %a"e -eenidentified#

CLINICAL FEATURESArthritis &rt%ritis is t%e most common presentin. s2mptom of &R)' 2et dia.nosticall2 it can-et%e most dicult# 0t is usuall2as2mmetrical and mi.rator2(one 4oint -ecomin.in1amed as anot%er su-sides)' -ut ma2-e additi"e (multiple 4oints pro.ressi"el2-ecomin. in1amed,it%out ,anin.)#Ear.e4oints are usuall2 aected'especiall2 t%e5nees and an5les# &rt%ritis of t%e %ip is often dicult to dia.nose -ecause o-4ecti"esi.nsma2-elimitedtoadecreasedran.eofmo"ement# 6%eart%ritisise8tremel2painful' oftenout ofproportiontot%eclinical si.ns# 0t ise8+uisitel2responsi"etotreatment ,it% non*steroidal anti*in1ammator2 dru.s (G!&0Ds)# 0ndeed't%is can -e auseful dia.nostic feature' as art%ritis continuin. una-ated more t%an 9 da2s after startin.G!&0D t%erap2 is unli5el2 to -e due to &R)# E+uall2' ,it%%oldin. G!&0Ds in patients,it% mono*art%ral.ia or mono*art%ritis to o-ser"e t%e de"elopment of pol2art%ritis canalso %elp in conHrmin. t%e dia.nosis of &R)#0n t%ese patients' paracetamol or codeinema2 -e used for pain relief# 7ecause of t%e mi.rator2 and e"anescent nature of t%eart%ritis' adeHnite%istor2ofart%ritis' rat%ert%andocumentation-2t%eclinician' is5sucient to satisf2 t%is criterion# &R) s%ould al,a2s -e considered in t%e dierentialdia.nosis of patients presentin.,it% art%ritis in %i.%*ris5 populations# 0nt%e %ospitalsettin.' p%2sicians and sur.eons s%ould colla-orate ,%en t%e dia.nosis of art%ritis isunclear#Patients,it%sterile4oint aspiratess%ouldne"er-etreatedspeculati"el2forseptic art%ritis ,it%out furt%er in"esti.ation' particularl2 in areas ,it% %i.% &R)IRHDpre"alence# $ono*art%ritis or pol2art%ral.ia is a common manifestation of &R)' and isoften associated ,it% o"ert or su-clinical carditis# 0n t%ese populations' aseptic mono*art%ritis or pol2art%ral.iama2-econsideredas ama4or manifestation' inplaceofpol2art%ritis# Ho,e"er' alternati"e dia.noses s%ould-e carefull2e8cluded# $ono*art%ritis ma2 also -e t%e presentin. feature if anti*in1ammator2 medication iscommenced earl2 in t%e illness prior to ot%er 4oints -ecomin. in1amed# 1Sydenhams chrea 6%is manifestation aects females predominantl2' particularl2 in adolescence# C%oreaconsists of 4er52' uncoordinated mo"ements' especiall2 aectin. t%e %ands' feet' ton.ueandface# 6%e mo"ements disappear durin.sleep# 6%e2ma2aect oneside onl2(%emic%orea)# Useful si.ns include:J 6%e Bmil5maid=s .ripC (r%2t%mic s+ueeKin. ,%en t%e patient .rasps t%e e8aminer=sHn.ers)J B!poonin.C (1e8ion of t%e ,rists and e8tension of t%e Hn.ers ,%en t%e %ands aree8tended)J 6%e Bpronator si.nC (turnin. out,ards of t%e arms and palms ,%en %eld a-o"e t%e%ead) and J 0na-ilit2 to maintain protrusion of t%e ton.ue#7ecause c%orea ma2 occur after a prolon.ed latent period follo,in. .roup &streptococcus (/&!) infection' t%e dia.nosis of &R) under t%ese conditions does notre+uire t%e presence of ot%er manifestations or ele"ated plasma streptococcal anti-od2titres#Patients,it%pure c%oreama2%a"e mildl2 ele"ated er2t%roc2te sedimentationrate (E!R' appro8 ;0mmI%r)' -ut %a"e a normal serum C*reacti"e protein (CRP) le"eland ,%ite cell count# C%orea is t%e &R) manifestation most li5el2 to recur' and is often6associated ,it% pre.nanc2 or oral contracepti"e use# 6%e "ast ma4orit2 of cases resol"e,it%inmont%s (usuall2 ,it%in,ee5s)' alt%ou.% rare cases lastin. as lon. as 9 2ears%a"e -een documented# 1Carditis &lt%ou.% pericarditis and m2ocarditis ma2 occur' cardiac in1ammation in &R) almostal,a2s aects t%e "al"es' especiall2 t%e mitral and aortic "al"es# Earl2 disease usuall2leads to "al"ular re.ur.itation# >it% prolon.ed or recurrent disease' scarrin. ma2 leadto stenotic lesions# &cute carditis usuall2 presents clinicall2 as an apical %olos2stolicmurmur ,it% or ,it%out a mid*diastolic 1o, murmur (Care2 Coom-s murmur)' or anearl2diastolicmurmurat t%e-aseoft%e%eart (aorticre.ur.itation)# 6%er%eumaticaetiolo.2canusuall2-e conHrmed-2a t2pical appearance onec%ocardio.rap%2#Con.esti"e %eart failure in &R) results from"al"ular d2sfunction secondar2 to"al"ulitis' and is not due to primar2 m2ocarditis# 0f pericarditis is present' t%e frictionru- ma2 o-scure "al"ular murmurs#1S!"c!tane!s nd!#es 6%ese are "er2 rare (less t%an 2@ of cases)# 6%e2 are 0#5:2#0cm in diameter' round'Hrm' freel2 mo-ile and painless nodules t%at occur in crops of up to 12 o"er t%e el-o,s',rists' 5nees' an5les'&c%illestendon' occiput andposteriorspinal processesoft%e"erte-rae# 6%e2 tend to appear 1:2 ,ee5s after t%e onset of ot%er s2mptoms' last onl21:2 ,ee5s (rarel2 more t%an 1 mont%) and are stron.l2 associated ,it% carditis#1 Erythema mar$inat!m Er2t%ema mar.inatum is also rare# &s ,it% su-cutaneous nodules' er2t%ema mar.inatumis %i.%l2 speciHc for &R)# 0t occurs as -ri.%t pin5 macules or papules t%at -lanc% underpressure andspreadout,ardsin a circularor serpi.inous pattern# 6%eras% can-edicult to detect in dar5*s5inned people' so close inspection is re+uired# 6%e lesionsare not itc%2 or painful' and occur on t%e trun5 and pro8imal e8tremities -ut almostne"er on t%e face# 6%e ras% is not aected -2 anti* in1ammator2 medication' and ma2recur for ,ee5s or mont%s' despite resolution of t%e ot%er features of &R)# 6%e ras% ma2-e more apparent after s%o,erin.#17Arthra#$ia &rt%ral.ia is a non*speciHc s2mptom' and usuall2occurs in t%e same pattern asr%eumatic pol2art%ritis (mi.rator2' as2mmetrical' aectin.lar.e4oints)# &lternati"edia.noses s%ould -e considered in a patient ,it% art%ral.ia t%at is not t2pical of &R)#1Fe%er >it% t%e e8ception of c%orea' most manifesta* tions of &R) are accompanied -2 fe"er#Earlier reports of fe"er descri-ed pea5 temperatures commonl2 .reater t%an 9DLC' -utlo,er .rade temperatures %a"e -een descri-ed more recentl2# &s t%ere are no recentdata relatin. to fe"er in lo,*ris5 populations' it is recommended t%at an oral' t2mpanicor rectal temperature .reater t%an 9FLC on admission' or documented durin. t%e currentillness' s%ould-econsideredasfe"er(Ee"el 0M'/radeC)# )e"er'li5eart%ritisandart%ral.ia' is usuall2 +uic5l2 responsi"e to salic2late t%erap2#1 E#e%ated ac!te&'hase reactants 62picall2' &R) patients %a"e a raised serum CRP le"el and E!R# 6%e perip%eral ,%ite-lood cell count is N15O10DIE in P5@ of patients' so an ele"ated ,%ite cell count is aninsensiti"e mar5er of in1ammation in &R)# )urt%er anal2sis of t%ese data demonstratedt%at less t%an ;@ of patients ,it% conHrmed &R)' e8cludin. c%orea' %ad -ot% a serumCRP le"el ofN90m.IE and an E!R of N90mmI%r# 6%erefore' it is recommended t%at aserumCRP le"el ofQ90m.IE orE!RofQ90mmI%risneededtosatisf2t%eminorcriterionofele"atedacute*p%asereactants#6%eserumCRP concentrationrisesmorerapidl2 t%an t%e E!R' and also falls more rapidl2 ,it% resolution of t%e attac5# 6%e E!Rma2 remain ele"ated for 9: mont%s' despite a muc% s%orter duration of s2mptoms#1 Pr#n$ed P&R inter%a# and ther rhythm a"nrma#ities !ome %ealt%2 people s%o, t%is p%enomenon' -ut a prolon.ed P*R inter"al t%at resol"eso"er t%e ensuin. da2s to ,ee5s ma2 -e a useful dia.nostic feature in cases ,%ere t%eclinical featuresarenot deHniti"e# E8tremeHrst*de.ree-loc5sometimesleadstoa4unctional r%2t%m' usuall2 ,it% a %eart rate similar to t%e sinus rate# !econd*de.ree' ande"en complete %eart -loc5' can occur and'if associated ,it% a slo, "entricular rate'ma2 .i"e t%e false impression t%at carditis is not si.niHcant#& small proportion %ad8more se"ere conduction a-normalities' ,%ic% ,ere sometimes found -2 auscultation orec%ocardio.rap%2 in t%e a-sence of e"idence of "al"ulitis#1 6%erefore' anelectrocardio.ram(EC/) s%ould-eperformedinall cases of suspected&R)0f aprolon.edP*R inter"al isdetected't%eEC/ s%ould-erepeated after1:2 mont%s todocument a return to normal#0f it %as returned to normal' &R) -ecomes a more li5el2dia.nosis# 6%e P*R inter"al increases normall2 ,it% a.e#1DIAGNOSIS&ccurate dia.nosis of &R) is important# O"er dia.nosis results in unnecessar2treatment o"er alon.time' ,%ileunder*dia.nosis leads tofurt%er attac5s of &R)'cardiac dama.e and premature deat%# Dia.nosis remains a clinical decision' as t%ere isno speciHc la-orator2 test# 6%e dia.nosis of &R) is usuall2 .uided -2 t%e Rones criteriaand t%e more recent >orld Healt% Or.aniKation (>HO) criteria#16%e Rones criteria for t%e dia.nosis of &R) ,ere introduced in 1D;;# 6%e criteria di"idet%e clinical features of &R)intoma4or andminor manifestations' -asedont%eirpre"alence and speciHcit2# $a4or manifestations are t%ose t%at ma5e t%e dia.nosis moreli5el2' ,%ereas minor manifestations are considered to -e su..esti"e' -ut insucient ont%eir o,n' for a dia.nosisof &R)# 6%e e8ception to t%is is in t%e dia.nosis of recurrent&R)#1910(OR) UPThrat c!#t!re6%roat culture findin.s for .roup & -eta %emol2tic Streptococcusare usuall2 ne.ati"e-2 t%e time s2mptoms of r%eumatic fe"er or r%eumatic %eart disease appear# &ttemptss%ould -e made to isolate t%e or.anism -efore t%e initiation of anti-iotic t%erap2 to %elpconfirm a dia.nosis of streptococcal p%ar2n.itis and to allo, t2pin. of t%e or.anism if itis isolated successfull2# PRa'id anti$en detectin test6%is test allo,s rapid detectionof .roup&streptococcal anti.enandallo,s t%edia.nosis of streptococcal p%ar2n.itis and t%e initiation of anti-iotic t%erap2 ,%ile t%epatient is still in t%e p%2sician?s office# 7ecause t%e rapid anti.en detection test %as aspecificit2 of .reater t%an D5@ -ut a sensiti"it2 of onl2 0*D0@' a t%roat culture s%ould-e o-tained in con4unction ,it% t%is test# PAntistre'tccca# anti"dies6%eclinical featuresofr%eumaticfe"er-e.inat t%etimeantistreptococcal anti-od2le"els are at t%eir pea5# 6%us' antistreptococcal anti-od2 testin. is useful for confirmin.pre"ious .roup &streptococcal infection# 6%e ele"ated le"el of antistreptococcalanti-odies is useful' particularl2in patients t%at present ,it% c%orea as t%e onl2dia.nosticcriterion# !ensiti"it2forrecent infectionscan-eimpro"ed-2testin.forse"eral anti-odies# &nti-od2titers s%ould-ec%ec5ed at 2*,ee5inter"als in order todetect a risin. titer#P6%e most common e8tracellular antistreptococcal anti-odies tested includeantistreptol2sin O (&!O)' antideo82ri-onuclease (DG&se) 7' anti%2aluronidase'antistrepto5inase' antistreptococcal esterase' and anti*DG &nti-od2 tests for cellularcomponents of .roup & streptococcal anti.ens include antistreptococcal pol2sacc%aride'antiteic%oic acid anti-od2' and anti:$ protein anti-od2# P0n .eneral' t%e ratio of anti-odies to e8tracellular streptococcal anti.ens rises durin. t%efirst mont% after infection and t%en plateaus for 9* mont%s -efore returnin. to normal11le"els after *12 mont%s# >%en t%e &!O titer pea5s (2*9 ,5 after t%e onset of r%eumaticfe"er)' t%e sensiti"it2 of t%is test is F0*F5@# 6%e anti*DG&se 7 %as a sli.%tl2 %i.%ersensiti"it2 (D0@) for detectin. r%eumatic fe"er or acute .lomerulonep%ritis#&nti%2aluronidaseresultsarefre+uentl2a-normalinr%eumaticfe"erpatients,it%anormal le"el of &!O titer and ma2 rise earlier and persist lon.er t%an ele"ated &!Otiters durin. r%eumatic fe"er#PAc!te 'hase reactants6%eC*reacti"eproteinander2t%roc2tesedimentationrateareele"atedinr%eumaticfe"er due to t%e inflammator2 nature of t%e disease# 7ot% tests %a"e a %i.% sensiti"it2-ut lo, specificit2 for r%eumatic fe"er# 6%e2 ma2 -e used to monitor t%e resolution ofinflammation' detect relapse ,%en ,eanin. aspirin' or identif2 t%e recurrence ofdisease# PHeart reacti%e anti"diesTropomyosin is elevated in acute reumatic fever! 7TREAT*ENT0ntramuscular 7enKat%ine penicillin/andoral PenicillinMare t%e recommendedantimicro-ial dru.sfort%etreatment of/&!# E8ceptinindi"idual,it%%istoriesofpenicillin aller.2# F6%e oralanti-iorics of c%oice arepenicillin M andamo8icillin#/enerall2' 250 m.2times dail2 is recommended for most c%ildren# & dose of 500 m. 2 to 9 imes dail2 isrecommended for adolescents and adults# &ll patient s%ould continue to ta5e penicillinre.ular2 for an entire 10 da2 period e"en t%ou.% t%e2 li5el2 ,ill -e as2mptomatic aftert%e first fe, da2s# Penicillin M is preferred to penicillin / -ecause it is more resistant to.astric acid# F7enKat%ine penicillin / s%ould -e considered particularl2 for patients ,%o are unli5el2to complete a 10 da2 course of oral t%erap2 and for patients ,it% personal of famil2%istories of r%eumatic fe"er or r%eumatic %eart disease or en"ironmental factors (suc% ascro,ded li"in. condition or lo, socioeconomic status) t%at place t%em at en%anced ris5for r%eumatic fe"er# 7enKat%ine penicillin / s%ould -e .i"en as a sin.le in4ection in a12lar.e muscle mass# 6%is formulation is painful' in4ection t%at contain procaine penicillin0nadditionto-enKat%inepenicillin/arelesspainful#6%erecommendeddosa.eof-enKat%inepenicillin/is00#000U0$forpatient ,%o,ei.%t 2P5.orlessand1#200#000 U for patient ,%o ,ei.%t more t%an 2P 5.# t%e com-ination of D00#000 U of-enKat%ine penicillin / and 900#000 U of procaine penicillin / is satisfactor2 t%erap2for most smaller c%ildren# 6%e efficac2 of t%is com-ination for %ea"ier patient suc% aslar.e teena.ers or adult re+uires furt%er stud2# &ller.ic reactions to penicillin are morecommon in adults t%an in c%ildren# F6%ere%as -eennosi.nificant c%an.e int%e mana.ement of acute R)in t%elast 502ears# Patientsneedpenicillinto eradicate/&! present in t%roat# &ntiinflammator2a.ents * aspirin or steroids * are used to control r%eumatic acti"it2# &spirin or steroids donot cure R)# 6%ese suppress t%e inflammator2 response ,%ic% lasts for a-out 12 ,5 inmore t%an F0 per cent patients# Hence' t%e standard dose of aspirin (D0*120 m.I5.Ida2)is .i"en for ten ,ee5s and tapered in t%e ne8t t,o ,ee5s# 6%e dose of prednisone 0m.Ida2 a-o"e 20 5. and ;0 m. Ida2 -elo, 20 5. in ,ei.%t is .i"en for t%ree ,ee5s andtapered in t%e ne8t nine ,ee5s# 6%e standard 12 ,ee5 course can -e reduced to four toei.%t ,ee5s dependin. on t%e patient=s response#

Patients ,it%out carditis can %a"e ,ee5l2 follo, up of E!R and CRP# 0f t%e2 normaliKe't%e course can -e reduced to a s%orter period# &spirin is preferred o"er steroids as lon.as t%e carditis is mild and t%e patient is not in con.esti"e failure# Ho,e"er' ,it% se"erecarditis and con.esti"e failure steroid is t%e dru. of c%oice -ecause of t%e more potentsuppressi"e effect#

Gon*steroidal anti*inflammator2 dru.s (G!&0Ds) %a"e not -een s2stematicall2 utiliKedto esta-lis% t%eir usefulness# 0mmunosuppressi"e a.ents li5e aKat%ioprine andc2closporine & %a"ealso-eenconsideredforacuter%eumaticfe"er#Despiteoft%econcerns of side effects'to8icit2andlate onset of l2mp%omas ,it%t%e use of t%eseimmunosuppressi"e it is possi-le to ar.ue t%at a s%ort course ofto F ,5 ma2 result ina .reater -enefit t%an %arm# Ho,e"er' most et%ics committees ,ill %esitate to permits2stematic testin. of t%ese a.ents#

0t is no, ,ell accepted t%at r%eumatic endocarditis in"ol"in. %eart "al"es is t%e maincauseof mor-idit2andmortalit2inR)# !ur.ical mana.ement consistin.of mitraland Ior aortic "al"e replacement in patients ,%ose con.esti"e failure cannot -e13controlled-2a..ressi"e medical treatment durin.acute R)' is life sa"in.# 0t t%econ.esti"e failure cannot -e controlled ,it% ma8imal medical t%erap2 and t%e patient isdeterioratin. due to mitral re.ur.itation' mitral "al"e replacement durin. acti"e R) isindicated# 0n spite of clinical e"idence for acti"e R)' t%e %eart siKe returns to normal andcon.esti"e failure disappears' confirmin. t%at r%eumatic m2ocarditis pla2s little or norole in t%e mortalit2 of R)#

$ana.ement of c%orea: 0t %as a self limitin. course' %ence parents need reassurance#6%ec%ildrencould-ereated,it%sedati"esli5ep%eno-ar-itone90m.t%ricedail2#c%lorpromaKine' "alium'dip%end2dramineorpromet%aKinecan -eused as sedati"es#Haloperidol 5to10m.t,icedail2%as-eenusedeffecti"el2# &lt%ou.%aspirinandsteroids are not supposed to %a"e a place in t%e treatment of c%orea' some patients %a"es%o,n dramatic response to steroids' if t%e2 do not s%o,ade+uate response tosedati"es#

!ince' lon. term follo, up of c%orea patients %a"e identified su-clinical carditis in 20 to90 per cent patients' penicillin prop%2la8is is essential and s%ould -e continued on alon. term -asis# R%eumatic %eart disease: !ur.ical mana.ement of "al"e disease ,ast%estandardapproac%till -alloonmitral "al"otom2,asintroducedin1DF5# $itralstenosis could -e corrected sur.icall2 eit%er -2 closed "al"otom2' opencommissurotom2 or -2 "al"e replacement if t%e "al"e ,as calcified# 7alloon "al"otom2pro"ides results as .ood as sur.ical "al"otom2 and %as -ecome t%e treatment of c%oicein spite of -ein. more e8pensi"e# )or mitral re.ur.itation t%e c%oice of treatment ,ould-e "al"e repair especiall2 in 2oun.er patients to a"oid lon.*term anti*coa.ulant t%erap2#$ost patients ,it% mitral or aortic "al"e re.ur.itation end up ,it% "al"e replacement#Hence' alt%ou.% sur.ical %elp is "er2 useful it is e8pensi"e and re+uires prolon.ed care,it% anticoa.ulant t%erap2 ,it% t%e associated complications of "al"e t%rom-osis ands2stemic em-olic disasters especiall2 in t%e lo,*income population of t%e countr2# O"eralon.follo,upperiodrelati"el2fe,patientsremainfreeofe"ent# 7alloonmitral"al"otom2%as -een utiliKed in t%e paediatric patients -elo,1*2 2r in a.e ,it%accepta-le results# 0t %as -een e8tended to patients of mitral stenosis#

PERICARDIAL EFFUSIONINTRODUCTION14Pericardial effusionist%epresenceof ana-normal amount of andor ana-normalc%aracter to fluid in t%e pericardial space# 0t can -e caused -2 a "ariet2 of local ands2stemic disorders' or it ma2 -e idiopat%ic#DPericardial effusions can -e acute or c%ronic' and t%e time course of de"elopment %as a.reat impact on t%e patient?s s2mptoms# 6reatment "aries' and is directed at remo"al oft%e pericardial fluid and alle"iation of t%e underl2in. cause' ,%ic% usuall2 is determined-2 a com-ination of fluid anal2sis and correlation ,it% comor-id illnesses#DPericardial effusion is a common findin. in clinical practice eit%er as incidental findin.or manifestation of a s2stemic or cardiac disease# 6%e spectrum of pericardial effusionsran.es from mild as2mptomatic effusions to cardiac tamponade# $oreo"er' pericardialeffusion ma2 accumulate slo,l2 or suddenl2#DUnfortunatel2' t%ere are fe, epidemiolo.ical data on t%e incidence and pre"alence ofsuc% effusions in t%e clinical settin.# 0n $aria Mittoria %ospital' an ur-an .eneral ospitalin6orino andan0talianreferral centre for pericardial diseases' t%e meanannualincidence and pre"alence of pericardial effusion %a"e -een' respecti"el2' 9 and D@ in aSears e8perience of t%e ec%o la-orator2#10!uc% data mainl2 depend on t%e epidemiolo.ical -ac5.round (especiall2 de"eloped "s#de"elopin.countr2',%eretu-erculosisisaleadin.causeofpericardial diseaseandconcurrent H0Minfectionma2%a"eanimportant promotin.role)' t%einstitutionalsettin. (tertiar2 referral centre "s# secondar2 and .eneral %ospitals)' and t%e a"aila-ilit2of specific su-specialties (especiall2 nep%rolo.2' r%eumatolo.2' and oncolo.2)# 10ETIOLOGY & ,ide "ariet2 of aetiolo.ic a.ents ma2 -e responsi-le of pericardial effusions' since all5no,n causes of pericardial disease ma2 -e causati"e a.ents# 6%e more common causesof pericardial effusions include infections ("iral' -acterial' especiall2tu-erculosis)'Cancer' connecti"e tissue diseases' pericardial in4ur2 s2ndromes (post*m2ocardialinfarction effusions' post*pericardiotom2 s2ndromes' post*traumatic Pericarditis eit%eriatro.enic or not)' meta-olic causes (especiall2 %2pot%2roidism' renal failure)'m2opericardial diseases (especiall2pericarditis' -ut alsom2ocarditis' %eart failure)'15aortic diseases' especiall2 aortic dissection e8tendin. into t%e pericardium' and selecteddru.s (i#e# mino8idil)# H2dropericardium' a non*inflammator2 transudati"e pericardialeffusion' ma2 occur not onl2 in %eart failure' -ut also s2ndrome' ,%en !tarlin. forcespromotet%eaccumulationofaplasmaultrafiltrateacrosst%epericardiumas,ellasot%er mem-ranes (e#.# pleura and peritoneum)# 100n t%e last 20 2ears' fi"e ma4or sur"e2s %a"e -een pu-lis%ed on t%e c%aracteristics ofmoderate to lar.e pericardial effusions# O-"iousl2' t%e relati"e fre+uenc2 of differentcauses depends on t%e local epidemiolo.2 (especiall2 t%e pre"alence of tu-erculosis)'t%e %ospital settin.' and t%e dia.nostic protocol t%at %as -een adopted# $an2 cases stillremainidiopat%icinde"elopedcountries(upto50@)' ,%ileot%er commoncausesinclude especiall2 cancer (10:25@)' pericarditis and infectious causes (15:90@)'iatro.enic causes (15:20@)' and connecti"e tissue disease (5:15@)' ,%ereastu-erculosis is t%e dominant cause in de"elopin. countries (0@)' ,%ere tu-erculosis isendemic#0n t%e settin. of pericarditis ,it% pericardial effusion' t%e pre"alence ofmali.nant or infectiousaetiolo.iesran.esfrom15to50@dependin.onpu-lis%edseries ad"anced %2poal-uminaemia' suc% as in cirr%osis and nep%ritic#10166a-le# Etiolo.2 Pericard Effusion17PATHOGENESIS6%e normal pericardial sac contains 10:50 mE of pericardial 1uid actin. as alu-riHcant -et,een t%e pericardial la2ers# !urprisin.l2' little is 5no,n a-out t%eformation and remo"al of pericardial 1uid' -ecause of t%epaucit2ofcompre%ensi"estudies' especiall2in%umansu-4ects' andmet%odolo.ical difHculties todistin.uis%-et,een t%e d2namics of normal pericardial 1uid and t%ose of a pat%olo.ical effusion#Ge"ert%eless' normal pericardial 1uid is .enerall2 considered an ultraHltrate of plasma#6%earran.ement ofl2mp%atic"esselsiscomple8and%as-eendescri-edin%umancada"ers# 6%e l2mp%atic "essels include different pat%,a2s accordin. to "entral' lateral'and posterior surfaces'-ut' in an2 case' terminate to mediastinal' trac%eo-ronc%ial' oriu8* taesop%a.eal l2mp% nodes# On t%e "entral surface' t%e l2mp%atics of t%e parietalpericardium connect to l2mp%atics in t%e pericardial fat and areolar tissue# On t%e lateralandposterior surfaces' t%el2mp%atics of t%eparietal pericardiumanastomose,it%l2mp%atics of t%e re1ected mediastinal pleura# E2mp%atic draina.e of t%e pericardium tot%e mediastinal and trac%eo-ronc%ial l2mp% nodes and interactions ,it% pleural pro"idet%e anatomical -asis for pat%olo.ical in"ol"ement of t%e pericardiumin speciHcdiseases (i#e# pleuro*pulmonar2diseases suc%as pulmonar2tu-erculosis andlun.cancer)# 11&n2pat%olo.ical processusuall2causesanin1ammator2process,it%t%epossi-leincreasedproductionofpericardial 1uid(e8udate)#&nalternati"emec%anismoft%eformationofperi*cardial 1uidma2-et%edecreasedrea-sorptionduetoincreaseds2stemic "enous pressure .enerall2 as a result of con.esti"e %eart failure or pulmonar2%2pertension (transudate)# 0f pericardial 1uid is free to mo"e ,it%in t%e pericardial sacfollo,in. t%e .ra"it2forces' it usuall2starts accumulatin. posteriorl2to t%e left"entricle ,%en t%e patient is la2in. on %isI%er left side for ec%ocardio.rap%ic e"aluation(mildeffusiondetectedinitiall2as posterior)' t%encircumferentiall2int%ecaseofmoderate to lar.e pericardial effusions# & mild pericardial effusion ma2 also -e detectedclose to t%e ri.%t atrium -ecause t%is is t%e cardiac c%am-er ,it% t%e lo,est pressures,it%in t%e cardiac c2cle and t%us pericardial 1uid accumulation is easier in t%is position#&nisolatedmildanterior pericardial 1uidis unusual onec%ocardio.rap%2,it%outpre"ious pericardial scarrin. as follo,in. sur.er2 or c%ronic pericarditis' and s%ould -ere.arded as fat rat%er t%an pericardial 1uid# 1118Computedtomo.rap%2(C6)orcardiacma.neticresonance(C$R)ma2conHrmt%eHndin.inspeciHccases# Ont%econtrar2afterpericardial scarrin.(i#e# aftercardiacsur.er2 or c%ronic pericarditis' or -acterial infections)' pericardial 1uid ma2 not %a"e auniformdistri-ution ,it%in t%e pericardial space and ma2 .i"e rise to loculatedeffusions t%at s%ould -e e"aluated ,it% multiple cardiac "ie,s# 6%e pressure "olumecur"eof t%enormal pericardiumisaR*s%apedcur"e: after aninitial s%ort s%allo,portiont%at allo,s t%epericardiumtostretc%sli.%tl2inresponsetop%2siolo.icale"ents' suc% as c%an.es in posture or "olume status' ,it% minimal pressure increase't%en t%e pericardium does not allo, furt%er sudden increases of t%e "olume ,it%out amar5ed increase in t%e intrapericardial pressure# 6%us a sudden increase of pericardial"olume of 100:200 mE' as in %aemopericardium' ma2 ele"ate pericardial pressure till20:90 mmH. ,it% acute cardiac tamponade (acute or sur.ical cardiac tamponade)# Ont%e contrar2 a slo,l2 accumulatin. pericardial 1uid ma2 allo, pericardial distention tillt%eaccumulationof 1:2Eof pericardial 1uid,it%out t%ede"elopment of cardiactamponadetillad"ancedsta.esoften-ecauseofintercurrente"ents(c%roniccardiactamponade or medical cardiac tamponade)#11CLINICAL *ANIFESTATION6%eclinical presentationofpericardial effusionis"ariedaccordin.tot%espeedofpericardial 1uid accumulation as mentioned in t%e introduction' and t%e aetiolo.2 of t%eeffusion ,it% possi-le s2mptoms t%at ma2 -e related to t%e causati"e disease# 6%e rateof pericardial 1uid accumulation is critical for t%e clinical presentation# 0f pericardial1uid is +uic5l2 accumulatin. suc% as for ,ounds or iatro.enic perforations' t%ee"olution is dramatic and onl2 small amounts of -lood are responsi-le of a +uic5 rise ofintrapericardial pressureando"ert cardiactamponadeinminutes# Ont%econtrar2aslo,l2 accumulatin. pericardial 1uid allo,s t%e collection of a lar.e effusion in da2s to,ee5s -efore asi.niHcant increaseinpericardial pressure-ecomes responsi-leofs2mptoms and si.ns# 9 Classical s2mptoms include d2spnoea on e8ertion pro.ressin. toort%opnoea'c%est pain'andIor fullness# &dditional occasional s2mptoms due to localcompressionma2include nausea (diap%ra.m)' d2sp%a.ia (oesop%a.us)' %oarseness(recurrent lar2n.eal ner"e)' and %iccups (p%renic ner"e)# GonspeciHc s2mptoms includealsocou.%' ,ea5ness' fati.ue' anore8iaandpalpitationsandre1ect t%ecompressi"e19effect of t%e pericardial 1uidonconti.uous anatomic structures or reduced-loodpressure and secondar2 sinus tac%2cardia#106%e classical Hndin.s of cardiac tamponade %a"e -een descri-ed -2t%e t%oracicsur.eon 7ec5 in 1D95# 7ec5 identiHed a triad includin. %2potension' increased 4u.ular"enouspressure' andasmalland+uiet%eart#6%istriad,asclassicall2identiHedinit% in1amedpericardium' t%e patient usuall2 %as t%e com-ination of effusion and pericardialt%ic5enin.# On C6' .enerall2' pericardial effusions are of lo, densit2 in t%e ran.e of 0:20 HounsHeld units (HU)# >%en t%e effusion contains %i.%er amounts of protein' suc%as in -acterial infections' or ,%en it is %aemorr%a.ic' its densit2 ma2 rise to 50 HU andmore# 0n1amed pericardium ma2 also s%o, contrast en%ancement# 0n C6 ima.in. of t%epericardium' difHcult2ma2-e encountered in differentiatin.1uidfromt%ic5enedpericardial tissue# Cardiac ma.netic resonance is superior to C6 in differentiatin. 1uid'especiall2%i.%l2proteinaceouse8udati"eeffusions' fromt%ic5enedpericardium# Ont%econtrar2'C6ma2detect e"enminimal amountsofpericardial calcium' ,%ereasC$Rma2miss si.niHcant deposits# Computedtomo.rap%2re+uires less timet%anec%ocardio.rap%2 and C$R# Ho,e"er' C6 re+uires t%e use of intra"enousl2administered iodinated contrast materials and ioniKin. radiation# $oreo"er' if performed,it%out EC/ .atin.' C6 ma2 lead to cardiac motion artefacts' t%at limit t%e e"aluationof pericardial t%ic5ness# Ho,e"er' t%e use of more recent and updated C6 scanners ,it%a .reater spatial and temporal resolution and more sop%isticated al.orit%ms for ima.ereconstructionma2allo,a si.niHcant reductioninC6ima.in.artefacts# Cardiacma.netic resonance%as asuperior a-ilit2toc%aracteriKe pericardial effusions andmasses,it%t%euseof acom-inationof 61,ei.%ted' 62*,ei.%ted' and.radient*recalledec%ocinese+uences,it%outt%euseofeit%eriodinatedcontrastmaterialorioniKin. radiation# Ho,e"er' a possi-le disad"anta.e of C$R ,it% EC/ .atin. is t%at23arr%2t%mias' often associated ,it% m2opericardial diseases' ma2 cause artefacts#&not%er disad"anta.e of C$R is related to its limited a"aila-ilit2 and %i.%er costs# Useof i#"# in4ected .adolinium ma2 -e useful for pericarditis detection' -ecause .adolinium%as-eenreportedtoen%ancein1amedpericardium' as,ell asfor t%edetectionofconcomitant m2ocardial in"ol"ement in m2opericarditis#1024)i.urePresentationofamild(&)"s# moderatetolar.epericardialeffusions(7)onec%ocardio.rap%2# $ild pericardial effusion is e"ident ad4acent to t%e ri.%t atrium infour*c%am-ers "ie,andonl2posterior inparasternal lon.*a8is "ie,(&)# &s 1uidaccumulates' t%eeffusion-ecomescircumferential (7)# Pe' pericardial effusionV R&'ri.%t atriumV &o' aorta#10TREAT*ENT!2mptoms andsi.ns su..esti"e of pericardial in"ol"ement ma2-e t%e presentin.clinical feature of eit%er primar2 or secondar2 mali.nant cardiac disease' -ut t%e2 aremuc% more fre+uentl2 present in patients under treatment for ad"anced mali.nanc2# Eifee8pectanc2 is s%ort as concomitant metastases are nearl2 al,a2s present else,%ere# 0nt%ese instances' ade+uate mana.ement of pericardial effusion ma2 contri-ute topalliation of t%e s2mptoms3ina si.nificant num-er of patients3andpossi-l2toprolon.edsur"i"al (inanundefinednum-erofcases)#&lt%ou.%t%emaincausesofdeat% in patients ,it%mali.nanc2are unrelated tocardiac in"ol"ement' insomenecrops2 series pericardial metastases are commonl2 found' particularl2 in lun. cancer(95@) and -reast cancer (25@) on t%e ot%er %and' cardiac s2mptoms are mainl2 relatedtot%epresenceoftamponade' ,%ic%ispresent inasi.nificant num-erofpatients'25alt%ou.% it %as no ne.ati"e impact on sur"i"al if it is correctl2 mana.ed# 0n patients ,it%mali.nanc2 and pericardial effusion t%e first step is to determine ,%et%er t%e effusion issecondar2 to neoplastic pericardial in"ol"ement or if it is an epip%enomenon(non*mali.nant effusion)relatedtot%emana.ement oft%ecancer(suc%aspre"ioust%oracic irradiation) or effusions of un5no,n ori.in# 0n t%ese t,o latter situations' anin"asi"e procedure ma2 -e ,arranted in t%e a-senceof tamponadeas t%e dia.nostic2ield of -ot% pericardial fluid and tissue is %i.% for mali.nanc2# 6%e mana.ement ofcardiactamponadeinpatients,it%secondar2neoplasticpericardial in"ol"ement%ast,otar.ets3relief of s2mptoms' andpre"entionof recurrences# Pericardiocentesisalle"iates s2mptoms in most cases# 0t is a safe' simple' and ,idel2 a"aila-le procedure,it% fe, complications if it is done under ec%ocardio.rap%ic .uidance# Pro-a-l2 it ist%e procedure of c%oice in end sta.e patients' ,%en recurrence of effusion is not a realissue# 0n patients sur"i"in. lon.er t%e pericardial fluid ma2 re*accumulate' and isolatedpericardicentesis pre"ents t%is in onl2 a-out 50@ of cases# 110n suc% patients a more a..ressi"e approac% ,it% sur.er2 ma2 -e ,arranted#Patientmana.ement %as to -e indi"idualiKed (t2pe and sta.e of neoplasm' .eneral condition'etc) as e"en t%e -est possi-le treatment for responsi"e t2pes of tumour (for e8ample'l2mp%oma) ,it% neoplastic pericardial in"ol"ement is associated ,it% sur"i"al of onl2a-out one 2ear#116%et%erap2of pericardial effusions%ould-etar.etedat t%eaetiolo.2asmuc%aspossi-le# 0n 0@ of cases' t%e effusion is associated ,it% a 5no,n disease' 1F and t%eessential treatment is t%at of t%e underl2in.disease# >%enpericardial effusionisassociated ,it% pericarditis' mana.ement s%ould follo, t%at of pericarditis#Ge"ert%eless' ,%en dia.nosis is still unclear or idiopat%ic' and in1ammator2 mar5ersare ele"ated' a trial of aspirin or a nonsteroidal anti*in1ammator2 dru. (G!&0D) can -eprescri-ed also to e"aluate t%e response# & "iral or idiopat%ic form is often responsi"e tosuc% empiric t%erap2# )or t%e mana.ement of recurrent in1ammator2 cases' t%e Hrst stepis considerin. t%e com-ination of aspirin or a G!&0D plus colc%icine' ,%ilecorticosteroids at lo, to moderate doses ma2 -e considered for speciHc indications (i#e#s2stemic in1ammator2 diseases and prenanc2)' and in case of intolerance'contraindications' or failure of aspirinIG!&0DV ot%er t%erapies are -ased on less solide"idence: less to8ic and less e8pensi"e dru.s (e#.# aKat%ioprine or met%otre8ate) s%ould26-e preferred' tailorin. t%e t%erap2 for t%e indi"idual patient and t%e p%2siciane8perience#0-uprofen is proposed as t%e fa"ourite Hrst c%oice for empiric anti*in1ammator2t%erap2 of pericarditis' due to rare side effects' fa"oura-le effect on t%e coronar2 1o,'and t%e lar.e dose ran.e# Ho,e"er' ot%er approac%es %a"e -een pu-lis%ed' and aspirin isused as Hrst fa"ourite c%oice in se"eral clinical trials in t%e settin. of acute and recurrentpericarditis# )or patients ,%o alread2 are ta5in. or need aspirin' suc% dru. is t%e -estanti in1ammator2c%oice# 0nt%e settin.of post*m2ocardial infarctionpericarditis'i-uprofen' ,%ic% increases t%e coronar2 1o,' is t%e preferred a.ent of c%oice accordin.#&spirin %as -een also successfull2 applied#10Ot%er nonsteroidal a.ents ma2 increase t%e ris5 of t%innin. t%e infarction Kone#Corticosteroidt%erap2can-eusedfor refractor2s2mptoms onl2' -ut coulddela2m2ocardial infarction %ealin. (class 00a indication' le"el of e"idence 7)# Post infarctionpericardial effusion U10 mm ma2 -e associated ,it% %aemopericardium' and up to t,o*t%irds of t%ese patients ma2 de"elop tamponadeIfree ,all rupture# 0n t%is settin.' ur.entsur.ical treatment is life sa"in.# Ho,e"er' if t%e immediate sur.er2 is not a"aila-le orcontraindicated' pericardiocentesis' andintrapericardial H-rin.lueinstillationcouldpro"ideanalternati"eimmediatetreatment# 0nt%esettin.ofautoreacti"epericardialeffusion' .ro,in.e"idencesupportst%epossi-leuseofintrapericardial t%erapiestoreduce side effects related to t%e oral use of corticosteroids#10>%en a pericardial effusion -ecomes s2mptomatic ,it%out e"idence of in1ammation or,%enempiricanti*in1ammator2dru.s arenot successful' draina.eof t%eeffusions%ould-econsidered# Pericardiocentesis,it%prolon.edpericardial draina.etill90mEI2; % is recommended to promote ad%erence of pericardial la2ers and pre"ent furt%eraccumulationof1uid' alt%ou.%e"idencetosupport t%isindicationis-asedoncasereports' retrospecti"e studies' and e8pert opinion# 0f pericardiocentesis is not feasi-le orfails' t%ecreationofasocalledpericardial ,indo,s%ould-econsideredeit%er-2con"entional %eart sur.er2 or "ideoassisted t%oracoscop2# 7alloon pericardiotom2 is analternati"e to sur.ical creation of a pericardial ,indo,' ,%ic% %as -een s%o,nsuccessful especiall2int%esettin.of neoplasticpericardial disease# 6%etec%ni+uein"ol"es insertin. a de1ated sin.le cat%eter or dou-le -alloon cat%eters into t%epericardial space usin. a su-8ip%oid approac% under 1uoroscopic or ec%ocardio.rap%ic27.uidance# &lt%ou.% successful in pre"entin. recurrence in F0@ of cases' stretc%in. oft%e pericardium is often painful so appropriate anal.esia is recommended#&recommendation to pericardiectom2 for fre+uent and %i.%l2 s2mptomatic recurrencesresistant to medical treatment# Ot%er reported indications include repeated recurrences,it%cardiactamponade' ande"idenceofserioussteroidto8icit2#&lt%ou.%sur.icale8periencesarenotal,a2sconcordant' pericardiectom2is.enerall2consideredasat%erapeutic option of dou-tful efHcac2 in recurrent idiopat%ic pericarditis or pericardialeffusionands%ould-econsideredonl2ine8* ceptional cases# C%ronicpermanentconstrictionremains t%ema4or indicationfor suc%inter"ention# Ho,e"er' incessantpericarditis' as distin.uis%ed fromrecurrent intermittent pericarditis' ma2 respondfa"oura-l2tosur.ical remo"al' especiall2int%e presence of recurrent pericardialeffusion# &n idiopat%ic c%ronic pericardial effusion is deHned as a collection ofpericardial 1uid t%at persists for 9 mont%s and %as no apparent causeV lar.e effusions%a"e a ris5 of pro.ression to cardiac tamponade (up to one t%ird' accordin. to a !panis%stud2)# On t%is -asis some aut%ors %a"e ad"ocated t%e need for pericardiectom2 for suc%cases' ,%ene"er a lar.e effusionrecurs after pericardiocentesis# !ince draina.e isrelati"el2 safe and eas2 in some cases ,it% .uided pericardiocentesis' draina.e %as -eenrecommended for lar.e su-acute effusions' t%at do not respond to empiric t%erap2' andare sta-le after se"eral ,ee5s (e#.# :F ,ee5s)' especiall2 ,%en t%ere are si.ns of ri.%tsidedcollapse' inordertopre"ent t%epossi-lepro.ressionoft%eeffusionto,ardstamponade follo,in. additional e"ents (e#.# pericarditis' -leedin. follo,in. c%esttrauma)#1228REFRENCES+, Natina# Heart F!ndatin - A!stra#ia and the Cardiac Sciety -A!stra#ia and Ne. /ea#and0 Dia$nsis and mana$ement - ac!te rhe!matic-e%er and rhe!matic heart disease in A!stra#ia0 1223,1, Indian Pediatric0 Cnsens!s G!ide#ines n Pediatric Ac!te Rhe!maticFe%er and Rhe!matic Heart Disease (r4in$ Gr!' On Pediatric Ac!teRhe!matic Fe%er and Cardi#$y Cha'ter O- Indian Academy O- Pediatric,5#!me 67, 1228,9, :Rem;nyi0 Ni$e# (i#sn0Andre.Steer0:eatriRis4Factrs0 PatientPr-i#esandCntem'rary*ana$ement,The Sciety Thracic S!r$en, 12+2,