Dr. George Lazaros,
A 53-year-old woman was admitted in hospital because of low grade fever of one week duration along with constricting chest pain, dyspnea, fatigue and myalgias. His past medical history was notable for a long-standing history of arterial hypertension treated with a fixed combination of b blocker and diuretic. The pain was retrosternal with irradiation to the neck and jaws. Notably, it was relieved by sitting up and leaning forward while it was worsening with inspiration cough and lying down.
On admission the patient was anxious but in a good overall condition. The blood pressure was 135/80mmHg without pulsus paradoxus. Physical examination was remarkable for the presence of a pericardial friction rub. Auscultation of the lungs reveled decreased breath sounds towards the base of both lungs. Moreover, jugular vein distension, mild ankle edema and presence of a palpable liver were detected as well.Laboratory evaluation revealed elevated C reactive protein levels (298mg/dl with normal values <5) along with normocytic normocromic anemia and mildly impaired renal and liver function. The rest of the hematologic tests, including high sensitivity troponin serum levels, quantiferon test for tuberculosis, serologic testing for connective tissue diseases and serum tumor markers was unremarkable. An ECG revealed sinus tachycardia (100bpm) along with non-specific ST-T wave changes and occasional supraventricular extrasystoles (Figure 1) whereas a chest x-ray showed an increased cardiothoracic ratio with bilateral pleural effusion, most prominent in the right hemithorax (Figure 2).
Figure 1. Electrocardiogram on admission disclosing sinus tachycardia along with non-specific ST-T wave changes and occasional supraventricular extrasystoles.
Figure 2. Chest x-ray in anteroposterior projection depicting an increased cardiothoracic ratio with bilateral pleural effusion. A chest computed tomography revealed moderate pericardial effusion and confirmed the presence of bilateral pleural effusion. Mediastinal lymph nodes sized up to 1.4mm were also found, without however evidence of parenchymal lung disease. Moreover, an abdominal CT scan was overall unremarkable. Transthoracic echocardiography performed on admission revealed moderate circumferential pericardial effusion (largest diameter in diastole of approximately 14mm at the lateral left ventricular wall) with overt and multiple thick fibrous adhesions within the pericardial space (Figure 3).
Figure 3. Chest computed tomography showing moderate pericardial effusion (white arrowheads) and bilateral pleural effusion (arrows)Pulse-wave Doppler of the mitral valve revealed a >25% decrease in E velocity of the mitral inflow during inspiration, whereas tissue Doppler imaging study revealed early diastolic E’ velocities in the septal annulus as compared with the lateral mitral annulus (annular inversus). Inferior vena cava was dilated with <<50% reduction in its diameter during inspiration (Figure 4). Figure 4. Two dimentional echocardiogram, 4-chamber view showing moderate pericardial effusion (between white arrowheads) and multiple thick fibrous adhesions within the pericardial space (black arrowhead). LV=left ventricle, RV=right ventricle, LA=left atrium, RA=right atrium, PE=pericardial effusion, LPLE=left pleural effusionHepatic veins interrogation with pulse Doppler revealed an increased diastolic flow with inspiration. A pronounced diastolic septal bounce was also detected. The rest of examination, including cardiac chambers dimension, left and right ventricular contractility and color Doppler assessment of the heart valves, were all normal. Figure 5. Panel A: Pulse wave Doppler interrogation of mitral inflow showing a >25% respiratory variation of the E velocity. Panels B and C: Tissue Doppler imaging study at the level of the mitral annulus disclosing a higher early diastolic E’ velocity in the septal annulus as compared with the lateral mitral annulus (annular inversus), Panel D: Inferior vena cava echocardiogram showing dilatation with insignificant variation in its dimensions with respiration.
1) Which among the following diagnoses is the most probable for the case described: acute pericarditis, recurrent pericarditis, constrictive or effusive-constrictive pericarditis or effusive constrictive pericarditis? 2) Is pericardiocentesis an appropriate treatment option for this patient? 3) In the presence of dyspnea fatigue, clinical and laboratory findings of peripheral stasis and constriction physiology in echocardiography is this patient a potential candidate for surgical total pericardiecomy?4) How should we treat this patient?
Authors: George Lazaros, Panagiotis Vasileiou, Dimitrios Tousoulis1st Department of Cardiology, University of Athens Medical School, Hippokration General Hospital, Athens, Greece.
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