SESSION TITLE: Cardiovascular Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Effusive constrictive pericarditis (ECP) is a rare pericardial disease characterized by concurrent constrictive physiology and pericardial effusion. We present a case of ECP in a patient with focal sclerosing glomerulonephritis (FSGS) with complete resolution of constrictive physiology after steroid therapy.
CASE PRESENTATION: A 73 year-old lady with past medical history of hypertension, cerebrovascular accident and chronic kidney disease due to FSGS (stage 4, glomerular filteration rate=25, blood urea nitrogen=30) presented with shortness of breath. Further work up revealed a large pericardial effusion without any evidence of tamponade physiology. She underwent diagnostic pericadiocentesis, which revealed hemorrhagic pleural effusion. Work up for malignancy was negative. Supportive therapy was commenced and she was discharged after index hospitalization. However, she was readmitted two weeks later with similar symptoms. Repeat echocardiogram showed significant resolution of pericardial effusion, with only small layer of pericardial fluid, but there was >35% respiratory variation of peak velocities (as measured by Doppler) at the tricuspid valve inflow (Figure A and B). She was started on a trial of oral steroid therapy for ECP. A repeat echocardiogram and left/right heart catheterization was performed 2 weeks after prednisone therapy, which showed complete resolution of constrictive physiology. Further work up for infective, inflammatory, uremic or autoimmune process was unrevealing. Possible association with FSGS could not be excluded.
DISCUSSION: Patients with ECP fail to show improvement in hemodynamic parameters after pericardiocentesis and will have features of constriction highlighting role of visceral pericardium causing constriction. A case series published by Sagristà-Sauleda et al showed predominance of idiopathic form amongst 15 patients with ECP of diverse etiology. This patient group improved with conservative measures such as steroids and non-steroidal anti-inflammatory agents and didn’t required visceral pericardectomy.
CONCLUSIONS: Although a rare entity, a high index of suspicion should be maintained for ECP when a patient with large pericardial effusion fails to improve symptomatically after pericardiocentesis. A trial of conservative strategy with prednisone therapy should be considered in idiopathic form of this disease in order to avoid high surgical risk pericardectomy .
Reference #1: Sagristà-Sauleda et al. N Engl J Med 2004;350:469-75.
Reference #2: Case Records of the Massachusetts General Hospital (Case 19-1997). N Engl J Med 1997;336:1812-9.
Reference #3: EW Hancock: New England Journal of Medicine, 2004
DISCLOSURE: The following authors have nothing to disclose: Abhishek Mishra, Maninder Singh, Zara Babayan, Daniel Sporn
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