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(Circulation. 2004;109:e146-e149.)
© 2004 American Heart Association, Inc.

Images in Cardiovascular Medicine

Constrictive Pericarditis in a Patient With Relapsed Acute Myelogenous Leukemia After Allogeneic Bone Marrow Transplantation

Raymond Wong, MBChB; Jean-Bernard Durand, MD; Mario A. Luna, MD; Daniel R. Couriel, MD; James L. Gajewski, MD

From the Departments of Blood and Marrow Transplantation (R.W., D.R.C., J.L.G.), Cardiology (J.-B.D.), and Pathology (M.A.L.), University of Texas M.D. Anderson Cancer Center, Houston, Tex.

Correspondence to James L. Gajewski, MD, Department of Blood and Marrow Transplantation, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 423, Houston, TX 77030. E-mail jgajewski{at}mail.mdanderson.org

A 43-year-old man presented with a month’s history of progressive dyspnea, orthopnea, and abdominal distension several months after having been diagnosed with relapsed acute monocytic leukemia after allogeneic bone marrow transplantation. His heart rate was 110 bpm, and blood pressure was 120/50 mm Hg with peripheral edema. Heart sounds were normal. Chest x-ray showed a small right pleural effusion with clear lung fields and normal cardiac size. His renal function deteriorated rapidly, with a rise of creatinine from 2.8 to 4.3 mg/dL within 1 day after admission. Echocardiogram revealed an ejection fraction of 55% to 60%, a thickened pericardium, and a small pericardial effusion with respiratory variation on mitral inflow, which was suggestive of constrictive pericarditis (Figure 1). The pressure tracing of a left and right heart catheterization showed equalization of diastolic pressures between the left ventricle and right ventricle with dynamic respiratory variations (Figure 2). Pericardiectomy was planned, but the patient developed sudden cardiorespiratory arrest and failed resuscitation. Postmortem examination disclosed monocytic leukemia in tumoral phase involving practically every organ. The pericardium was markedly thickened with multiple, yellow-tan–colored nodules with an appearance resembling fish flesh, which measured up to 1 cm (Figure 3). Histology confirmed monocytic leukemic infiltration (Figure 4). Death was attributed to constrictive pericarditis secondary to leukemic infiltration.

View larger version (29K): [in this window] [in a new window]   Figure 1. A, Two-dimensional echocardiography done before transplantation (in October 2001) showing mild pericardial thickening. B, Two-dimensional echocardiography performed on admission with heart failure (April 2002), showing markedly thickened pericardium along posterior wall. C, M-mode echocardiography showing variation of transmitral flow with respiration.

View larger version (90K): [in this window] [in a new window]   Figure 2. A, Telemetry monitoring and left ventricular pressure tracings. Telemetry shows sinus tachycardia in leads II and III. Left ventricular pressure tracing shows marked respiratory arterial variations. B, Telemetry monitoring and simultaneous right ventricular (RV) and left ventricular (LV) pressure recordings. The upper panel shows sinus tachycardia with heart rate of 104 bpm in lead II and lead III. The lower panel tracings of LV and RV pressure demonstrate a collaboration of RV and LV diastolic pressures and a characteristic dip in plateau contour of the diastolic wave forms.

View larger version (97K): [in this window] [in a new window]   Figure 3. The heart showing (A) the pericardium and epicardium with multiple yellow-tan–colored nodules with an appearance resembling fish flesh, the largest measuring 1 cm. B, Cross section of the heart shows markedly thickened pericardium.

View larger version (147K): [in this window] [in a new window]   Figure 4. A, Dense, mononuclear infiltrate in the visceral pericardium (left side of the photograph) by leukemic cells (hematoxylin and eosin, x40). B, The parietal pericardium is also densely infiltrated by leukemic cells (hematoxylin and eosin, x40).

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wong, R. Articles by Gajewski, J. L. Search for Related Content PubMed PubMed Citation Articles by Wong, R. Articles by Gajewski, J. L. Pubmed/NCBI databases Medline Plus Health Information Bone Marrow Transplantation