Abstract 1759: A 27 year-old Man from ’the Valley’ with Shortness of Breath
A 27 year-old man with no significant past medical history was admitted with shortness of breath and subjective fevers. He was diagnosed with Valley fever based on pulmonary infiltrates on chest x-ray and elevated Coccidiomycosis immitis IgG and IgM titers and was treated with antifungal therapy. He subsequently developed worsening dyspnea, orthopnea, and lower extremity swelling. On exam his jugular venous pressure was elevated and he had bilateral pleural effusions, lower extremity edema, and a positive Kussmaul sign. The electrocardiogram showed sinus tachycardia with diffuse T-wave inversions. Echocardiography demonstrated thickened adhesive pericardium, exaggerated respirophasic variation of the tricuspid and mitral inflow Doppler patterns and a prominent septal bounce. Cardiac MRI showed markedly thickened enhancing pericardium with an associated small pericardial effusion and prominent septal bounce. There was no delayed enhancement to suggest myocarditis. Cardiac catheterization showed equalization of diastolic pressures in all four chambers, low cardiac output, and simultaneous right and left ventricular pressures showed respirophasic discordance suggestive of increased ventricular interdependence. All of the above findings were consistent with constrictive pericarditis in the setting of disseminated coccidioidomycosis, and the patient underwent urgent surgical pericardiectomy with improvement in his symptoms. Pathology specimens demonstrated fungal spherules and active inflammation consistent with Coccidiomycosis immitis infection of the pericardium. This case illustrates the multi-disciplinary diagnostic approach that is often needed to distinguish constrictive pericarditis from restrictive cardiomyopathy. It highlights classic features of constrictive physiology seen on imaging and cardiac catheterization in a unique case of fungal pericarditis. Pericardial involvement in disseminated coccidioidomycosis is rare, and constrictive pericarditis treated with pericardiectomy has been described in only two prior cases in the literature.