A Rare Pericardial Disease

Answer: C. Constrictive Pericarditis

Discussion

The chest films show prominent pericardial calcifications. At age 19, the patient had multiple stab wounds to his thorax, penetrating his pericardium and requiring thoracotomy. Over the ensuing years, this was complicated by recurrent pericardial effusions, requiring multiple pericardiocenteses. His echocardiogram showed a stiff right ventricle with reduction in RV function and a paradoxical septal motion, findings consistent with constrictive pericarditis¹.

Causes of constrictive pericarditis include idiopathic (46%), prior cardiac surgery (37%), radiation (9%), and miscellaneous causes (8%) such as chest trauma, tuberculosis, and autoimmune diseases². Perioperative mortality from pericardiectomy is 6%. However, without pericardiectomy, the disease usually progresses to death². The patient underwent pericardiectomy and was eventually discharged home after a prolonged hospital course. Unfortunately, he died shortly after discharge from heroin overdose at home.

Choice A was incorrect as pulmonary embolism does not usually lead to pericardial effusion. In addition, his symptoms are chronic rather than acute. Choice B is incorrect as myocarditis patients would typically have ECG findings suggestive of acute myocardial injury along with troponin elevation. Choice D is incorrect since systolic heart failure would typically present with pulmonary edema on the CXR in addition to other signs of generalized volume overload.

References

1. Ling LH, Oh JK, Breen JF, et al. Calcific constrictive pericarditis: is it still with us? Ann Intern Med 2000; 132(6): 444-50.
2. Bertog SC, Thambidorai SK, Parakh K, et al. Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. J Am Coll Cardiol 2004; 43(8): 1445-52.