A Case of Transient Constrictive Pericarditis
A 25-year-old man with a 2-year history of recurrent chest pain secondary to relapsing pericarditis presented with several days of pleuritic chest pain at a local hospital. There, he was found to have a mildly elevated troponin T and an initial ECG showing ST-segment elevations consistent with acute pericarditis. He had received a dose of intravenous Decadron with resolution of symptoms within 1 day. Ten days later, he again developed significant chest pain and fever, and presented for further evaluation. On presentation, he was febrile to 40°C, exhibited no evidence of pulsus paradoxus, and had normal first and second heart sounds without a pericardial rub. Jugular venous pressure was elevated, with a rapid “y” descent. A transthoracic echocardiogram revealed thickening of his pericardium, with a rind around the heart of 1.5-cm maximal thickness. He also had constrictive hemodynamics and was tachycardic to 128 bpm during the examination. Chest CT was done, showing generalized thickening of the pericardium measuring 12 mm over the right ventricular free wall (Figure 1). There also was a moderate-sized left pleural effusion with associated compressive atelectasis of the adjacent left lower lobe lung tissue and mild dilatation of the inferior vena cava.
The patient was admitted for further evaluation and was found to have a leukocytosis of 19.9×109 cells/L with a left shift on his differential, as well as an elevated sedimentation rate of 67 mm/hour. He was given 60 mg oral prednisone and had improvement of his symptoms and fever resolution within 24 hours. He was discharged on a 1.5-month taper of prednisone. When he was examined 2 months later, his symptoms had resolved. He was found to have a normal echocardiogram with normal hemodynamics and a tiny, insignificant pericardial effusion seen only in systole. A repeat chest CT (Figure 2) showed interval improvement of the previously noted pericardial thickening. Pericardial thickness was 3 mm over the right ventricular free wall.
Increased pericardial thickness in a subset of patients with constrictive pericarditis is the result of acute inflammation and can be managed conservatively with a trial of 1 to 2 months of an antiinflammatory agent.