Pediatric Malignant Pericardial Effusion


Background

Pericardial involvement in patients with malignancy is common. [12Widespread use of noninvasive diagnostic techniques, such as echocardiography and computed tomography (CT) scanning, has increased awareness of this diagnosis. The mere presence of pericardial effusion does not necessarily imply pericardial infiltration by malignant cells.

Pericardial malignancy is often asymptomatic. It is observed on chest radiography performed to evaluate the lungs or diagnosed as an incidental finding at autopsy. It can also present in antenatal scans, especially with fetal teratoma. Although pericardial malignancy may be reported as an incidental finding, it may have contributed to the symptoms and even to death.

Medical care is dictated mainly by the general condition of the patient and the underlying malignancy. The safety and effectiveness of surgical drainage of pericardial fluid via pericardiectomy (complete or partial) or the creation of a pericardial window are well recognized. Further inpatient care is determined by the underlying condition. Further outpatient care is often required to look for evidence of constrictive pericarditis. 

Pathophysiology

The pericardium consists of 2 layers, the visceral pericardium (epicardium) and the parietal pericardium, which enclose a potential space (ie, the pericardial cavity) between them. This cavity is normally lubricated by a very small amount of serous fluid (< 30 mL in adults). Inflammation of the pericardium or obstruction of lymphatic drainage from the pericardium of any etiology causes an increase in fluid volume, referred to as a pericardial effusion.

Malignant involvement of the pericardium may be primary (less common) or secondary (spreading from a nearby or distant focus of malignancy). Secondary neoplasms can involve the pericardium by contiguous extension from a mediastinal mass, nodular tumor deposits from hematogenous or lymphatic spread, and diffuse pericardial thickening from tumor infiltration (with or without effusion). In diffuse pericardial thickening, the heart may be encased by an effusive-constrictive pericarditis.

Other rare mechanisms include chronic myelomonocytic leukemia and intrapericardial extramedullary hematopoiesis with preleukemic conditions or during blast crisis in chronic myeloid leukemia. Obstruction of lymphatic drainage by mediastinal tumors, either benign or malignant, can also give rise to pericardial effusion, which can be chylous. These mechanisms may act independently or jointly in any particular child with malignancy. The underlying myocardium is not involved in most patients.

Pathogenesis of clinical manifestations

In healthy individuals, the pericardium does not limit filling of the cardiac chambers either at rest or during exercise. When pericardial effusion occurs, chamber capacity may be reduced. Venous return may be severely limited, and thus, cardiac output may also be severely limited. The capacity of the pericardial space is influenced by its natural stiffness. Rapid accumulation of fluid is poorly tolerated, whereas slow accumulation may allow large amounts of pericardial fluid to collect without producing symptoms.

When pressure is increased within the pericardial space, filling pressure is elevated in all chambers of the heart. In advanced stages, right and left atrial mean pressures and right and left ventricular end-diastolic pressures are virtually identical to the intrapericardial pressure. Therefore, the clinical features result from the limitation of cardiac output and elevated venous pressures.

Pulsus paradoxus

In healthy individuals, inspiration causes the systolic blood pressure to fall slightly as a result of the greater volume of blood accommodated by the pulmonary vascular bed. This occurs despite inspiratory increase in venous return to the right heart. In cardiac tamponade, right ventricular filling is maintained at the expense of restricted left ventricular filling, and the systolic blood pressure falls further (>10 mm Hg).

This exaggerated fall in systolic blood pressure with inspiration is referred to as pulsus paradoxus. It is an important sign of cardiac tamponade, though on occasion, severe respiratory distress of any cause (asthma, emphysema, pleural effusion) may give rise to this sign.

Etiology

Primary malignant neoplasms that may give rise to pericardial effusion include the following:

Metastatic or infiltrative diseases that may give rise to pericardial effusion include the following:

Epidemiology

Pericardial effusion is a common cause of pericarditis, occurring in approximately 5-15% of US patients with malignant neoplasms, according to autopsy data. Most cardiac tumors in infants and children are benign (eg, rhabdomyoma and fibroma) and are unlikely to be associated with pericardial involvement. [4A study of 236 children in Poland reported cardiac involvement in 15% of children, including pericardial effusion in 7% of children. [5A review from the United States ranked pericardial effusion as an important oncologic emergency. [6]

Age- and sex-related demographics

Children of all ages are affected, but pericardial effusion is more common in older children and adolescents. In a study by Medary et al, the mean age was 14 years. [7This finding may be related to the longer survival of older children with malignancy. Both sexes are affected. Medary et al reported a higher incidence in males than in females, with a ratio of 7:3. [7]

Prognosis

Children with pericardial involvement due to malignancy have more extensive disease and hence a worse prognosis; pericardial tamponade may add to the mortality unless promptly detected and appropriately treated. [58Educate patients about cardiac symptoms of tamponade and the need to follow up with regular examination.

Detection of malignant cells in pleural, peritoneal, and pericardial fluids of patients with cancer marks the presence of metastatic disease, usually establishing a grave prognosis; however, all patients with malignancy and pericardial effusion do not have metastatic involvement.

Immediate relief of large effusions is essential to prolong survival.

CLINICAL PRESENTATION


History

Pericardial malignancy is often asymptomatic. It is observed on chest radiography performed to evaluate the lungs or diagnosed as an incidental finding at autopsy. It can also present in antenatal scans, especially with fetal teratoma. [910Although pericardial malignancy may be reported as an incidental finding, it may have contributed to the symptomatology and even death. A review of some cases leads to the conclusion that symptoms may be incorrectly attributed to the underlying neoplasm.

Shortness of breath or dyspnea is the most common symptom (85%). Other manifestations may include chest pain, shoulder pain, and a hacking cough that varies with posture. Sitting up and leaning forward improves the cough. Orthopnea may be present.

Primary cardiac malignancy presents as unresponsive heart failure. In rare instances, cardiac tamponade may be the initial manifestation of systemic malignancy. Infrequently, pericardial malignancy may present as superior venacaval syndrome, either due to a coexisting tumor mass or just resulting from the rapid accumulation of pericardial effusion. [11]

Physical Examination

Central venous pressure is increased. Jugular venous pressure is elevated, and jugular veins are not pulsatile.

The liver may be enlarged, and peripheral edema and ascites may be present. Encountering evidence of pulmonary edema is unusual, because pericardial effusion limits the amount of blood that can enter the heart, and the left atrial pressure does not exceed the right atrial pressure.

Heart sounds may be distant or faint. Pericardial friction rub may be observed. A sign of pericardial inflammation is a grating, scratching sound caused by abrading of inflamed pericardial surfaces with cardiac motion. Pericardial friction rub may have as many as 3 components.

In the presence of a large effusion, heart sounds may be muffled, and the rub may disappear. It is best heard in the second through fourth intercostal spaces along the left sternal border or along the midclavicular line, and it is loudest in the upright position with the patient leaning forward. The rub is often accentuated in inspiration.

The occasional persistence of a rub in pericardial tamponade is believed to reflect friction between the inflamed parietal pericardium and the pleura.

Ewart sign—that is, subscapular dullness to percussion—may be observed. This sign reflects compression of the left lung by a massively enlarged heart and may be associated with abnormal breath sounds in that region. No crepitations or rhonchi are heard.

Characteristic features of cardiac tamponade are as follows:

  • Low cardiac output

  • Elevated central venous pressures

  • Paradoxical pulse

  • Muffled or diminished heart sounds

  • Tachycardia

  • Jugular venous distention reflecting high central venous pressure

  • Low systolic blood pressure and low pulse pressure

Pulsus alternans may be present. This consists of a drop in systolic blood pressure in alternate beats, another ominous sign. This sign is most reliably documented by observing intra-arterial blood pressure tracings, rather than by palpating the pulse itself.

Congenital intrapericardial tumors may be associated with fetal hydrops secondary to compression of fetal venous structures.

Complications

Complications of pediatric malignant pericardial effusion include the following:

  • Cardiac tamponade (mostly occurring in infants but also reported in older children) [12]

  • Sudden death

  • Retinoic acid syndrome – Retinoic acid syndrome is characterized by fever and respiratory distress, along with weight gain, pleural or pericardial effusions, peripheral edema, thromboembolic events, and intermittent hypotension; these are related to all trans- retinoic acid therapy for underlying malignancy

  • Leukemic coronary artery occlusion

DDx

Diagnostic Considerations

Failure to diagnose and appropriately react to the presence of a pericardial effusion is a potential medicolegal pitfall. In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:

  • Drug-induced pericardial disease (eg, from hydralazine, isoniazid, or procainamide)

  • Purulent pericarditis

  • Radiation pericarditis

  • Tuberculous pericarditis

  • Uremic pericarditis

  • Doxorubicin- and daunorubicin-related pericarditis or myocardial dysfunction

  • Cystic lymphangioma

  • Effusion possibly related to pre–bone-marrow transplant drug conditioning

  • Malignant hepatic involvement with portal hypertension

  • Microvascular tumor spread in lungs with secondary pulmonary hypertension

  • Pericardial celomic cyst (unilocular)

  • Pericardial teratoma

  • Superior venacaval obstruction of any cause

  • Chylous or lymphatic pericardial effusions, whether (1) from congenital thoracic cystic hygroma with pericardial involvement, (2) occurring after surgery for congenital heart disease complicated by elevated venous pressures or trauma to the thoracic duct, or (3) developing secondary to obstruction of lymphatic drainage by mediastinal masses

Differential Diagnoses

Workup

Laboratory Studies

The following blood investigations may be ordered, as dictated by the patient’s general condition:

  • Complete blood cell (CBC) count with platelet count and white blood cell (WBC) differential

  • Blood film (smear)

  • Serum chemistry

  • Erythrocyte sedimentation rate (ESR)

  • C-reactive protein (CRP) level

  • Blood cultures

Levels of the following markers of specific malignancy may help in assessing disease progression:

  • Serum alpha-fetoprotein (AFP)

  • Serum cancer antigen (CA)-125

The following markers of malignancy in pericardial fluid cells may be useful:

  • Human telomerase reverse transcriptase (hTERT) mRNA expression may be detected in abnormal cells in body fluids by using in situ hybridization (ISH)

  • Molecular genetic studies can also be helpful in the analysis of lymphocyte-rich serous pericardial effusion.

  • An immunocytochemical test panel has also been suggested in selected cases

  • Vascular endothelial growth factor levels are elevated in malignant pericardial effusion. [13]

Double immunohistochemical antibody studies for EZH2 nuclear staining and MOC-31 membranous staining on serosal effusions may help clinicians to differentiate between benign and malignant effusions. [1In a retrospective study of 142 patients diagnosed with either benign (n = 53) or malignant (n = 89) cytology on the basis of clinical, radiologic, histopathologic, and follow-up data, no benign cases expressed EZH2 or MOC-31 markers, whereas 93% and 96% of the malignant cases, respectively, expressed these markers. [1]

Electrocardiography

Changes on electrocardiography (ECG) are nonspecific and may represent the effect of pericardial inflammation on the underlying myocardium.

Low voltage QRS complexes (35%) are seen, especially with moderate to large effusions. ST-segment elevation is found. T-wave inversion is noted. Development of arrhythmias (eg, atrial tachycardia, atrial fibrillation, or heart block) is observed. Electrical alternans (seen in 17% of cases), a beat-to-beat variation in QRS amplitude, occurs with excessive motion of the heart within the fluid-filled pericardial space.

Chest Radiography

Chest radiography reveals varying degrees of cardiomegaly, depending on the amount of pericardial fluid and its rate of accumulation (see the image below). Rapidly accumulating effusion is associated with relatively minimal cardiomegaly, whereas massive effusions produce a large cardiac shadow, causing the characteristic water-bottle heart or triangular heart with smoothed-out cardiac borders.

Plain chest radiograph from 3-month-old infant witPlain chest radiograph from 3-month-old infant with pneumonia and malignant pericardial effusion, showing cardiomegaly and bilateral pneumonic patches.

Pleural effusion, mediastinal widening, hilar mass, or, less commonly, irregular nodular contour of the cardiac silhouette or a bony or parenchymal metastatic deposit may indicate underlying disease. Rarely, pericardial calcification may be evident.

Echocardiography

Echocardiography is the primary study performed for diagnosis and quantification of the effusion, as well as for guidance of needle pericardiocentesis. Echocardiography has a 96% diagnostic accuracy in pericardial effusion.

Pericardial fluid gives the appearance of an echo-free space between the epicardial and pericardial reflections. This is evident in both 2-dimensional images (see the first image below) and M-mode images (see the second image below).

Two-dimensional echocardiograph from subcostal winTwo-dimensional echocardiograph from subcostal window, showing large pericardial effusion.
M-mode echocardiograph from child with pericardialM-mode echocardiograph from child with pericardial effusion.

When effusion is minimal, it accumulates posterior to the left ventricle and is more apparent in systole. When effusion is massive, fluid is observed all around the heart and throughout the cardiac cycle. Diastolic ventricular filling is abnormal secondary to cardiac compression.

A swinging motion of the heart may be observed within the pericardial cavity, along with abnormalities of septal motion, dilation of the inferior vena cava, and loss of respiratory caval motion. Irregular undulating masses that protrude into the pericardial space, the atria, the ventricles, or even the pulmonary arteries are reported.

Hemodynamic impairment or cardiac tamponade is deemed to be present in the presence right atrial collapse (buckling of the right atrial wall into the right atrium) in late diastole and/or right ventricular free-wall collapse in early diastole. [14Exaggeration of respiratory variation in transvalvar Doppler flow velocities is seen with tamponade. [15; decreased transmitral Doppler flow velocity greater than 30% during inspiration compared with expiration may be indicative of cardiac tamponade and may require pericardial decompression by a pericardial tap or other means as per the patient’s clinical status.

Fetal echocardiography can identify fetal pericardial effusion secondary to fetal pericardial malignancy (most commonly, teratoma).

Transesophageal echocardiography (TEE) provides information regarding the presence and location of space-occupying masses within the pericardium.

CT, MRI, and Radionuclide Imaging

Computed tomography (CT) scanning reveals the thickness and density of the pericardium and content of the pericardial space. It aids in the identification of constrictive pericarditis by providing additional information on the status of the vena cava, atria, ventricles, and pleura. The minimum amount of pericardial fluid that can be detected by CT scanning is estimated to be 10 mL. CT scanning provides added information regarding the presence and location of space-occupying masses within the pericardium and the adjacent mediastinum and lungs.

Magnetic resonance imaging (MRI) provides added information regarding the presence and location of space-occupying masses within the pericardium and the adjacent mediastinum and lungs. [16In addition, this technique is more sensitive than CT in differentiating malignant lesions from benign ones.

Radionuclide imaging can demonstrate a pericardial effusion in previously undiagnosed pericardial disease.

Diagnostic Pericardial Drainage

Pericardial drainage is used to diagnose the cause of the malignant effusion, assess the cytology, and treat hemodynamic compromise in the presence of cardiac tamponade. In a study of 480 pericardiocentesis specimens, investigators determined that a minimum volume of more than 60 mL is required for cytologic evaluation to ensure an adequate diagnosis of pericardial fluids. [17When compared with pericardial biopsy, cytology of pericardial fluid volumes below 60 mL had a 70.0% sensitivity and detected fewer malignancies.

Malignancy may be first suspected from pericardial fluid analysis in as many as 5% of these patients. A catheter drainage technique is commonly used. Ultrasonographic guidance adds to the safety of the procedure, [18but it is not a requisite with emergency drainage.

For pericardiocentesis, insert a beveled, sharp needle beneath the xiphoid process, and angle upward and leftward toward the left shoulder. Sometimes, a pop is felt as the needle is passed into the pericardium. Attempt to withdraw fluid with each advance of the needle. If fluid is obtained, remove enough to alleviate tamponade. Even a small amount often provides significant benefit.

Process the pericardial fluid for cytology, biochemistry, and culture and sensitivity, including viral and fungal cultures in relevant cases. Exudates differ from transudates in that they demonstrate higher leukocyte counts, lower glucose levels, higher protein contents, and higher specific gravity. Cytospin preparations can be stained with Wright-Giemsa stain to identify cellular morphology that, in turn, can be used to test for immunologic markers and for electron microscopy.

Potential complications of the procedure include myocardial puncture, coronary artery or vein laceration, hemopericardium, laceration of the internal mammary artery, pneumothorax, and liver and aortic injury.

In the presence of significant effusion, maintain good hydration and effective filling pressures to help maintain perfusion until pericardiocentesis can be performed.

Continuous closed drainage of the pericardial space is accomplished by advancing a pigtail catheter over a guide wire. This is necessary for patients in whom the effusion reaccumulates rapidly.

Video-thoracoscopic pericardial drainage is a safe and effective for loculated pericardial effusions previously treated by percutaneous drainage maneuvers and patients with concomitant pleural disease. [1920Percutaneous balloon pericardiotomy has also been tried for management of recurrent malignant pericardial effusion. [2122]

Fetal pericardiocentesis has been used in the treatment of pericardial effusion secondary to fetal teratoma. Pericardioamniotic shunting has been tried in fetal malignant pericardial effusion, with variable success. [9]

Pericardial Biopsy

Specimens for pericardial biopsy can be obtained either by open pericardiotomy or during thoracotomy (the latter is relatively rare). Pericardial biopsy has a sensitivity of approximately 55% for diagnosing malignant involvement; however, when used in conjunction with cytologic analysis of the pericardial fluid, it has a sensitivity of nearly 100%.

Open pericardial biopsy may be required if initial cytologic analysis yields negative results. Obtaining a larger biopsy specimen by means of open biopsy should provide a histologic diagnosis in as many as 90% of cases. The procedure carries significant risk in patients who are critically ill, but a false-negative diagnosis may occur if the tissue sample is too small.

Biopsy specimens are subjected to histologic and immunohistologic examination, polymerase chain reaction (PCR) evaluation, or in situ hybridization (ISH) analysis for microbial DNA and ribonucleic acid. [23]

Other Diagnostic Procedures

Pericardioscopy can reveal neoplastic effusions both by permitting direct observation and by obtaining a biopsy of the pericardium for further analysis.

Cardiac catheterization is not required for diagnosis of pericardial effusion. However, there are potential indications for its use, such as the following:

  • Suspected superior venacaval obstruction and pulmonary microvascular tumor (lymphangitic tumor) may occur with malignant cardiac tamponade and contribute to the development of facial edema and jugular venous distention

  • Cyanosis, hypoxemia, and elevated pulmonary vascular resistance may indicate pulmonary microvascular tumor (lymphangitic tumor); the diagnosis can be established by obtaining a blood sample for cytologic analysis from the pulmonary capillary wedge position using the right-heart catheter

Histologic Findings

Malignant pericardial effusion is often hemorrhagic or serosanguineous, but these findings alone are not sufficient to differentiate neoplastic causes from radiation-related or idiopathic causes. Because treatment strategies differ, it is essential to carry out a meticulous cytologic examination of the pericardial fluid (see the images below) so as to help differentiate malignant pericarditis from other causes of pericardial effusion.

Cytologic features of malignant pericardial effusiCytologic features of malignant pericardial effusion. Smear of centrifuged pericardial fluid from patient with malignant pericardial involvement from lymphoma. Low-power view showing numerous mononuclear cells along with large atypical malignant cells.
Cytologic features of malignant pericardial effusiCytologic features of malignant pericardial effusion. Smear of centrifuged pericardial fluid from patient with malignant pericardial involvement from lymphoma. High-power view showing morphologic details of malignant cells. These cells are large and show oval hyperchromatic nuclei, some of them having nucleoli. Cytoplasm is reduced to thin rim.

False-negative results on cytology are uncommon in carcinomatous pericarditis, but when such a result does occur, it may be due to scant cellularity or the presence of obscuring blood. False-negative results are more common with lymphoma and mesothelioma. Chylothorax is most often reported with mediastinal lymphangioma.

Detection of malignant cells in effusions is facilitated by immunocytochemistry studies using a wide panel of antibodies. [24BerEP4 and B72.3 appear to be the best markers when both sensitivity and specificity are considered, followed by BG8. Carcinoembryonic antigen (CEA) and CA-125 have a limited role in the detection of metastases from gynecologic tumors because the former has low sensitivity and the latter has low specificity.

Flow cytometry can also be used to detect DNA diploidy (reflecting a benign condition) and aneuploidy (reflecting a malignancy), but the results have not been uniformly convincing. The low sensitivity of flow-cytometric DNA analysis does not favor its routine use.

TREATMENT AND MANAGEMENT


Approach Considerations

Medical care is dictated mainly by the general condition of the patient and the underlying malignancy. It is important to remember that almost 50% of patients with symptomatic pericardial effusion and neoplastic disease have a nonmalignant cause, such as radiation-related, idiopathic, infectious (including tuberculous and fungal), and lymphatic obstruction.

Transfer pediatric patients with a pericardial effusion to a facility that provides pediatric cardiology and cardiovascular services. If a diagnosis of malignancy is suspected, immediate availability of pediatric oncologists is necessary.

Hemodynamic support is of some value until drainage of pericardial fluid can be accomplished. Pericardiocentesis and intrapericardial sclerosis are effective therapies for malignant pericardial effusions that recur. Intrapericardial administration of drugs (eg, cisplatin) can be important. Anti-inflammatory drugs may be used for viral pericarditis.

No special diet requirements are necessary. Restrict activity only to the limit of intolerance. Further outpatient care is often required to look for evidence of constrictive pericarditis.

Pericardial Drainage

In addition to its diagnostic role (see Workup), pericardial drainage is used to treat hemodynamic compromise in the presence of cardiac tamponade.

The safety and effectiveness of surgical drainage of pericardial fluid via pericardiectomy (complete or partial) or the creation of a pericardial window are well recognized. This procedure removes fluid that is excessively thick. Perform open surgical drainage if purulent pericarditis is present. Obtain biopsy specimens from the pericardium and the epicardium.

Total pericardiectomy may be required, especially in the presence of a thickened pericardium that has a constricting effect. Thoracotomy may be required to arrive at a complete diagnosis.

Pericardioamniotic shunting has been tried in fetal malignant pericardial effusion, with variable success. [9]

Consultations

The following consultations may be helpful:

  • Pediatrician

  • Pediatric cardiologist

  • Pediatric oncologist

  • Radiologist

  • Nuclear medicine specialist

  • Cardiothoracic surgeon

  • Physiotherapist

  • Occupational therapist

  • Specialist nurse

  • Family physician

MEDICATION

Medication Summary

Hemodynamic support is of some value until drainage of pericardial fluid can be accomplished. Pericardiocentesis and intrapericardial sclerosis are effective therapies for malignant pericardial effusions that recur. Intrapericardial administration of drugs, such as cisplatin, can be important. Use anti-inflammatory drugs for viral pericarditis.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Class Summary

Nonsteroidal anti-inflammatory drugs (NSAIDs) are analgesics that offer anti-inflammatory action. They have analgesic, anti-inflammatory, and antipyretic activities. Their main mechanism of action is inhibition of cyclooxygenase activity and prostaglandin synthesis. They may act through other mechanisms as well (eg, by inhibiting leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions).

Ibuprofen (Advil, Motrin, Addaprin, Ultraprin)

Ibuprofen is a propionic acid derivative that reduces the formation of inflammatory mediators by enzyme inhibition.

Naproxen (Aleve, Anaprox, Naprosyn, Naprelan)

Naproxen is a propionic acid derivative that reduces the formation of inflammatory mediators by enzyme inhibition.

Diclofenac sodium (Cataflam, Voltaren SR, Zipsor)

Diclofenac possesses properties similar to those of the propionic acid derivatives and reduces the formation of inflammatory mediators by enzyme inhibition. The tablets are immediate-release formulations.

Indomethacin (Indocin)

Indomethacin behaves in the same manner as the propionic acid derivatives and inhibits the formation of inflammatory mediators. It is rapidly absorbed and is metabolized in the liver through demethylation, deacetylation, and glucuronide conjugation. Indomethacin inhibits prostaglandin synthesis.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Corticosteroids

Class Summary

Corticosteroids elicit anti-inflammatory and immunosuppressive properties and cause profound and varied metabolic effects. They modify the body’s immune response to diverse stimuli.

Prednisone

Prednisone is used for patients with severe inflammatory pericardial effusions or for those in whom initial treatment with NSAIDs has failed.

Methylprednisolone (Solu-Medrol, Depo-Medrol, A-Methapred)

Methylprednisolone is available in IV/IM and oral form. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. It is used for patients with severe inflammatory pericardial effusions or for those in whom initial treatment with NSAIDs has failed.

Prednisolone (Pediapred, Prelone, Orapred, Millipred)

Prednisolone is available in tablet and liquid forms. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. It is used for patients with severe inflammatory pericardial effusions or for those in whom initial treatment with NSAIDs has failed.

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