- Email: [email protected]
Transient constrictive pericarditis following acute idiopathic pericarditis. A case report
+
MODEL
Hellenic Society of Cardiology (2017) xx, 1e4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/ hellenic-journal-of-cardiology/
LETTER TO THE EDITOR
Transient constrictive pericarditis following acute idiopathic pericarditis. A case report
KEYWORDS acute pericarditis; transient constrictive pericarditis; permanent constriction
A 53-year-old woman was admitted in hospital because of low-grade fever of 1-week duration along with chest pain, dyspnea, fatigue, and myalgias. Her past medical history was notable for long-standing arterial hypertension treated with a fixed combination of a beta-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 worsened with deep inspiration, cough, and lying down. On admission, the patient was anxious but in a good overall condition. The blood pressure was 135/80 mmHg without pulsus paradoxus. Physical examination was remarkable for the presence of a pericardial friction rub. Auscultation of the lungs revealed decreased breath sounds toward the base of both lungs. Moreover, jugular vein distension, mild ankle edema, and presence of a palpable liver 3 cm below the right costal margin were detected. Laboratory evaluation revealed greatly elevated C reactive protein levels (298 mg/dl with normal values <5) along with mild elevation of creatinine and aminotransferases (both approximately 1.5 the upper limit of normal). The rest of the hematologic tests, including highsensitivity troponin serum levels, quantiferon test for tuberculosis, serologic screening for connective tissue diseases, thyroid hormone levels, and serum tumor marker measurements were unremarkable.
An ECG revealed sinus tachycardia (w100 bpm) along with non-specific ST-T wave changes and occasional supraventricular extrasystoles, whereas a chest X-ray showed an increased cardiothoracic ratio with bilateral pleural effusion. A chest computed tomography revealed moderate pericardial effusion and confirmed the presence of bilateral pleural effusion, however, without evidence of parenchymal lung disease or other chest disorder (Figure 1A). Moreover, an abdominal CT scan was overall unremarkable. Transthoracic echocardiography performed on admission revealed moderate circumferential pericardial effusion (with the largest diameter in diastole being approximately 14 mm at the lateral left ventricular wall) with overt and multiple thick fibrous adhesions within the pericardial space (Figure 1B). A pronounced paradoxical diastolic bouncing motion of the interventricular septum was also detected. Pulse wave Doppler of the mitral valve revealed a >25% decrease in E velocity during inspiration (Figure 1C), whereas tissue Doppler imaging study revealed higher early diastolic E0 tissue velocities in the septal mitral annulus than in the lateral mitral annulus (the so-called sign of mitral annular reversus). Inferior vena cava was dilated without any inspiratory collapse (Figure 1D), whereas hepatic vein interrogation with pulse wave Doppler revealed diastolic flow reversal with expiration. All of the above findings were consistent with constrictive physiology. The rest of the examination, including cardiac chambers dimension, left and right ventricular contractility, and color Doppler assessment of the heart valves was unremarkable.
Peer review under responsibility of Hellenic Society of Cardiology. http://dx.doi.org/10.1016/j.hjc.2017.07.005 1109-9666/ª 2017 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Lazaros G, et al., Transient constrictive pericarditis following acute idiopathic pericarditis. A case report, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.07.005
+
MODEL
2
Letter to the Editor
Figure 1 Panel A: Chest computed tomography showing moderate pericardial effusion (white arrowheads) and bilateral pleural effusion (white arrows). Panel B: Two dimensional echocardiogram, four-chamber view, showing moderate pericardial effusion (between white arrowheads) and multiple thick fibrous adhesions within the pericardial space (black arrowhead). Panel C: Pulse wave Doppler interrogation of mitral inflow showing a >25% respiratory variation of the E velocity. Panel D: Inferior vena cava echocardiogram showing dilatation with absence of inspiratory collapse. LVZleft ventricle, RVZright ventricle, LAZleft atrium, RAZright atrium, PEZpericardial effusion, LPLEZleft pleural effusion, IVCZinferior vena cava.
Considering all the above, the patient was diagnosed with idiopathic acute effusive pericarditis (as more than 2 of 4 criteria that are required for the diagnosis of acute pericarditis were fullfiled, namely pericarditic chest pain and pericardial effusion1,2) with clinical and echocardiographic features of pericardial constriction. In the presence of an intense inflammatory component, as dictated by the high CRP values, she was treated with ibuprofen 600 mg tid, colchicine 0.5 mg bid, and a proton-pump inhibitor. Her symptoms improved rapidly, and 15 days later she was asymptomatic and the CRP normalized. Most importantly, a regression of all clinical and echocardiographic signs of constriction was observed (Figure 2). Subsequently, ibuprofen was tapered and finally discontinued after a total of 5 weeks administration. Colchicine was given for 3 months according to the ICAP trial recommandation.3 In a 3-year follow-up, the patient was asymptomatic, free of recurrences, and without any clinical or echocardiographic evidence of chronic constrictive pericarditis. This is a case of acute idiopathic pericarditis with transient constriction, which subsided with anti-inflammatory
treatment. Transient constrictive pericarditis was reported for the first time by Sagrista-Sauleda et al. in 9% of patients with acute effusive pericarditis during the resolution phase of the effusion.4 In a subsequent retrospective review of the Mayo Clinic database, which is the largest available, this entity was observed in 17% of the 212 patients first presenting with clinical and echocardiographic findings of constrictive pericarditis.5 The average time interval between the initial diagnosis and resolution of the disorder was 8.3 weeks, and the most common cause was cardiovascular surgery (25%), followed by idiopathic forms (22%). Reported symptoms consisted of chest pain (53% of cases), dyspnea (44%), fever, edema, and fatigue, whereas 8% of patients were asymptomatic. Transient constriction may reverse either spontaneously or after anti-inflammatory regimens (either with steroidal or non-steroidal medications).5,6 The key message of this case is that in patients presenting for the first time with clinical and imaging findings compatible with pericardial constriction (namely “acute” constrictive pericarditis, either in the late phase of acute effusive pericarditis or without a clear relationship with a pericardial syndrome), the permanent or transient nature of pericardial
Please cite this article in press as: Lazaros G, et al., Transient constrictive pericarditis following acute idiopathic pericarditis. A case report, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.07.005
+
MODEL
Letter to the Editor
3
Figure 2 Follow-up echocardiography 12 days after the initial study. Panel A: Four-chamber view showing regression of the pericardial effusion. Panel B: Insignificant respiratory variation of the E velocity of mitral inflow. Panel C: restoration of inferior vena cava dimension and respiratory variation (arrows). IVCZinferior vena cava.
constriction should be investigated before eventual referral for total pericardiectomy. Accordingly, a trial of conservative anti-inflammatory treatment for 2-3 months may be attempted before referral for pericardiectomy, which is the recommended treatment option in symptomatic patients with permanent constriction.7 Serum CRP elevation and moderate or severe pericardial late gadolinium enhancement (LGE) along with LGE pericardial thickness >3 mm can predict reversibility of constriction.8,9 In contrast, patients with evidence of severe advanced disease (long standing symptoms, hemodynamic instability, advanced functional class III-IV, presence of cardiac cachexia, atrial fibrillation, extensive pericardial calcification, and, finally, no evidence of ongoing inflammation) should undergo pericardiectomy without further delay. In conclusion, awareness of transient constrictive pericarditis is of paramount importance to avoid unnecessary
pericardiectomy procedures. In doubtful cases, cMRI may provide important clues and guide management.
References 1. Lazaros G, Vlachopoulos C, Stefanadis C. Idiopathic recurrent pericarditis: searching for Ariadne’s thread. Hellenic J Cardiol. 2009;50:345e351. 2. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36:2921e2964. 3. Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369: 1522e1528. 4. Sagrista `-Sauleda J, Permanyer-Miralda G, Candell-Riera J, Angel J, Soler-Soler J. Transient cardiac constriction: an unrecognized pattern of evolution in effusive acute idiopathic pericarditis. Am J Cardiol. 1987;59:961e966.
Please cite this article in press as: Lazaros G, et al., Transient constrictive pericarditis following acute idiopathic pericarditis. A case report, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.07.005
+
MODEL
4 5. Haley JH, Tajik AJ, Danielson GK, Schaff HV, Mulvagh SL, Oh JK. Transient constrictive pericarditis: causes and natural history. J Am Coll Cardiol. 2004;43:271e275. 6. Lazaros G, Vasileiou P, Danias P, et al. Effusive-constrictive pericarditis successfully treated with anakinra. Clin Exp Rheumatol. 2015;33:945. 7. Lazaros G, Imazio M, Brucato A, Tousoulis D. Untying the Gordian knot of pericardial diseases: A pragmatic approach. Hellenic J Cardiol. 2016;57:315e322. 8. Chrysohoou C, Antoniou CK, Stillman A, Lalude O, Henry T, Lerakis S. Myocardial fibrosis detected with gadolinium delayed enhancement in cardiac magnetic resonance imaging and ventriculoarterial coupling alterations in patients with acute myocarditis. Hellenic J Cardiol. 2016;57:449e454. 9. Feng D, Glockner J, Kim K, et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation. 2011;124:1830e1837.
Letter to the Editor George Lazaros* Konstantinos Konstantinou Oyrania Katsarou Areti Koumeli Evelina Bei Dimitrios Tousoulis 1st Department of Cardiology, University of Athens Medical School, Hippokration General Hospital, Athens, Greece *Corresponding author. George Lazaros, MD FESC, First Cardiology Department, University of Athens, Hippokration Hospital, 114 Vas. Sofias Ave., 115 27 Athens, Greece. Tel.: þ30 2132088099; fax: þ30 2132088676. E-mail address: [email protected] (G. Lazaros) 11 June 2017
Please cite this article in press as: Lazaros G, et al., Transient constrictive pericarditis following acute idiopathic pericarditis. A case report, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.07.005
MODEL
Hellenic Society of Cardiology (2017) xx, 1e4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.journals.elsevier.com/ hellenic-journal-of-cardiology/
LETTER TO THE EDITOR
Transient constrictive pericarditis following acute idiopathic pericarditis. A case report
KEYWORDS acute pericarditis; transient constrictive pericarditis; permanent constriction
A 53-year-old woman was admitted in hospital because of low-grade fever of 1-week duration along with chest pain, dyspnea, fatigue, and myalgias. Her past medical history was notable for long-standing arterial hypertension treated with a fixed combination of a beta-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 worsened with deep inspiration, cough, and lying down. On admission, the patient was anxious but in a good overall condition. The blood pressure was 135/80 mmHg without pulsus paradoxus. Physical examination was remarkable for the presence of a pericardial friction rub. Auscultation of the lungs revealed decreased breath sounds toward the base of both lungs. Moreover, jugular vein distension, mild ankle edema, and presence of a palpable liver 3 cm below the right costal margin were detected. Laboratory evaluation revealed greatly elevated C reactive protein levels (298 mg/dl with normal values <5) along with mild elevation of creatinine and aminotransferases (both approximately 1.5 the upper limit of normal). The rest of the hematologic tests, including highsensitivity troponin serum levels, quantiferon test for tuberculosis, serologic screening for connective tissue diseases, thyroid hormone levels, and serum tumor marker measurements were unremarkable.
An ECG revealed sinus tachycardia (w100 bpm) along with non-specific ST-T wave changes and occasional supraventricular extrasystoles, whereas a chest X-ray showed an increased cardiothoracic ratio with bilateral pleural effusion. A chest computed tomography revealed moderate pericardial effusion and confirmed the presence of bilateral pleural effusion, however, without evidence of parenchymal lung disease or other chest disorder (Figure 1A). Moreover, an abdominal CT scan was overall unremarkable. Transthoracic echocardiography performed on admission revealed moderate circumferential pericardial effusion (with the largest diameter in diastole being approximately 14 mm at the lateral left ventricular wall) with overt and multiple thick fibrous adhesions within the pericardial space (Figure 1B). A pronounced paradoxical diastolic bouncing motion of the interventricular septum was also detected. Pulse wave Doppler of the mitral valve revealed a >25% decrease in E velocity during inspiration (Figure 1C), whereas tissue Doppler imaging study revealed higher early diastolic E0 tissue velocities in the septal mitral annulus than in the lateral mitral annulus (the so-called sign of mitral annular reversus). Inferior vena cava was dilated without any inspiratory collapse (Figure 1D), whereas hepatic vein interrogation with pulse wave Doppler revealed diastolic flow reversal with expiration. All of the above findings were consistent with constrictive physiology. The rest of the examination, including cardiac chambers dimension, left and right ventricular contractility, and color Doppler assessment of the heart valves was unremarkable.
Peer review under responsibility of Hellenic Society of Cardiology. http://dx.doi.org/10.1016/j.hjc.2017.07.005 1109-9666/ª 2017 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Lazaros G, et al., Transient constrictive pericarditis following acute idiopathic pericarditis. A case report, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.07.005
+
MODEL
2
Letter to the Editor
Figure 1 Panel A: Chest computed tomography showing moderate pericardial effusion (white arrowheads) and bilateral pleural effusion (white arrows). Panel B: Two dimensional echocardiogram, four-chamber view, showing moderate pericardial effusion (between white arrowheads) and multiple thick fibrous adhesions within the pericardial space (black arrowhead). Panel C: Pulse wave Doppler interrogation of mitral inflow showing a >25% respiratory variation of the E velocity. Panel D: Inferior vena cava echocardiogram showing dilatation with absence of inspiratory collapse. LVZleft ventricle, RVZright ventricle, LAZleft atrium, RAZright atrium, PEZpericardial effusion, LPLEZleft pleural effusion, IVCZinferior vena cava.
Considering all the above, the patient was diagnosed with idiopathic acute effusive pericarditis (as more than 2 of 4 criteria that are required for the diagnosis of acute pericarditis were fullfiled, namely pericarditic chest pain and pericardial effusion1,2) with clinical and echocardiographic features of pericardial constriction. In the presence of an intense inflammatory component, as dictated by the high CRP values, she was treated with ibuprofen 600 mg tid, colchicine 0.5 mg bid, and a proton-pump inhibitor. Her symptoms improved rapidly, and 15 days later she was asymptomatic and the CRP normalized. Most importantly, a regression of all clinical and echocardiographic signs of constriction was observed (Figure 2). Subsequently, ibuprofen was tapered and finally discontinued after a total of 5 weeks administration. Colchicine was given for 3 months according to the ICAP trial recommandation.3 In a 3-year follow-up, the patient was asymptomatic, free of recurrences, and without any clinical or echocardiographic evidence of chronic constrictive pericarditis. This is a case of acute idiopathic pericarditis with transient constriction, which subsided with anti-inflammatory
treatment. Transient constrictive pericarditis was reported for the first time by Sagrista-Sauleda et al. in 9% of patients with acute effusive pericarditis during the resolution phase of the effusion.4 In a subsequent retrospective review of the Mayo Clinic database, which is the largest available, this entity was observed in 17% of the 212 patients first presenting with clinical and echocardiographic findings of constrictive pericarditis.5 The average time interval between the initial diagnosis and resolution of the disorder was 8.3 weeks, and the most common cause was cardiovascular surgery (25%), followed by idiopathic forms (22%). Reported symptoms consisted of chest pain (53% of cases), dyspnea (44%), fever, edema, and fatigue, whereas 8% of patients were asymptomatic. Transient constriction may reverse either spontaneously or after anti-inflammatory regimens (either with steroidal or non-steroidal medications).5,6 The key message of this case is that in patients presenting for the first time with clinical and imaging findings compatible with pericardial constriction (namely “acute” constrictive pericarditis, either in the late phase of acute effusive pericarditis or without a clear relationship with a pericardial syndrome), the permanent or transient nature of pericardial
Please cite this article in press as: Lazaros G, et al., Transient constrictive pericarditis following acute idiopathic pericarditis. A case report, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.07.005
+
MODEL
Letter to the Editor
3
Figure 2 Follow-up echocardiography 12 days after the initial study. Panel A: Four-chamber view showing regression of the pericardial effusion. Panel B: Insignificant respiratory variation of the E velocity of mitral inflow. Panel C: restoration of inferior vena cava dimension and respiratory variation (arrows). IVCZinferior vena cava.
constriction should be investigated before eventual referral for total pericardiectomy. Accordingly, a trial of conservative anti-inflammatory treatment for 2-3 months may be attempted before referral for pericardiectomy, which is the recommended treatment option in symptomatic patients with permanent constriction.7 Serum CRP elevation and moderate or severe pericardial late gadolinium enhancement (LGE) along with LGE pericardial thickness >3 mm can predict reversibility of constriction.8,9 In contrast, patients with evidence of severe advanced disease (long standing symptoms, hemodynamic instability, advanced functional class III-IV, presence of cardiac cachexia, atrial fibrillation, extensive pericardial calcification, and, finally, no evidence of ongoing inflammation) should undergo pericardiectomy without further delay. In conclusion, awareness of transient constrictive pericarditis is of paramount importance to avoid unnecessary
pericardiectomy procedures. In doubtful cases, cMRI may provide important clues and guide management.
References 1. Lazaros G, Vlachopoulos C, Stefanadis C. Idiopathic recurrent pericarditis: searching for Ariadne’s thread. Hellenic J Cardiol. 2009;50:345e351. 2. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36:2921e2964. 3. Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369: 1522e1528. 4. Sagrista `-Sauleda J, Permanyer-Miralda G, Candell-Riera J, Angel J, Soler-Soler J. Transient cardiac constriction: an unrecognized pattern of evolution in effusive acute idiopathic pericarditis. Am J Cardiol. 1987;59:961e966.
Please cite this article in press as: Lazaros G, et al., Transient constrictive pericarditis following acute idiopathic pericarditis. A case report, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.07.005
+
MODEL
4 5. Haley JH, Tajik AJ, Danielson GK, Schaff HV, Mulvagh SL, Oh JK. Transient constrictive pericarditis: causes and natural history. J Am Coll Cardiol. 2004;43:271e275. 6. Lazaros G, Vasileiou P, Danias P, et al. Effusive-constrictive pericarditis successfully treated with anakinra. Clin Exp Rheumatol. 2015;33:945. 7. Lazaros G, Imazio M, Brucato A, Tousoulis D. Untying the Gordian knot of pericardial diseases: A pragmatic approach. Hellenic J Cardiol. 2016;57:315e322. 8. Chrysohoou C, Antoniou CK, Stillman A, Lalude O, Henry T, Lerakis S. Myocardial fibrosis detected with gadolinium delayed enhancement in cardiac magnetic resonance imaging and ventriculoarterial coupling alterations in patients with acute myocarditis. Hellenic J Cardiol. 2016;57:449e454. 9. Feng D, Glockner J, Kim K, et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation. 2011;124:1830e1837.
Letter to the Editor George Lazaros* Konstantinos Konstantinou Oyrania Katsarou Areti Koumeli Evelina Bei Dimitrios Tousoulis 1st Department of Cardiology, University of Athens Medical School, Hippokration General Hospital, Athens, Greece *Corresponding author. George Lazaros, MD FESC, First Cardiology Department, University of Athens, Hippokration Hospital, 114 Vas. Sofias Ave., 115 27 Athens, Greece. Tel.: þ30 2132088099; fax: þ30 2132088676. E-mail address: [email protected] (G. Lazaros) 11 June 2017
Please cite this article in press as: Lazaros G, et al., Transient constrictive pericarditis following acute idiopathic pericarditis. A case report, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/j.hjc.2017.07.005