Transient Constrictive Pericarditis With Videographic Display of Kussmaul Sign
A 24-year-old white man with no significant past medical history presented with sharp chest pain that increased with inspiration and radiated to his left shoulder and neck. The pain had begun 1 week before presentation. The patient denied accompanying shortness of breath, dizziness, palpitations, edema, or syncope. The patient recalled having had an upper respiratory infection that he presumed was viral ≈2 weeks before this admission. A review of systems was noncontributory. He denied any unusual exposures. He used alcohol occasionally and denied recreational drug use.
On examination, he was afebrile with a blood pressure of 110/56 mm Hg, pulse rate of 90 bpm, and normal oxygen saturations. Pulsus paradoxus of 13 mm Hg was measured, and no jugular venous distension was noted. He appeared to be in moderate distress from the pain. Cardiac examination revealed faint heart sounds without a pericardial rub or murmurs. Complete blood count and serum chemistries were within normal limits. Three sets of cardiac enzyme measurements were negative. The chest radiograph revealed moderate cardiomegaly suggestive of pericardial effusion (Figure 1). The ECG showed diffuse concave ST elevation and PR-segment depression across multiple limb and chest leads consistent with pericarditis (Figure 2). Transthoracic echocardiography revealed an ejection fraction of 55% to 60% and a moderately sized effusion. Significant respiratory variation of mitral inflow pattern was noted; however, no right atrial or ventricular collapse was seen.
Acute pericarditis of probable viral or idiopathic origin with moderate effusion and borderline hemodynamic significance was diagnosed. Conservative management with high-dose ibuprofen at 800 mg 3 times daily was initiated. The patient’s pain and pulsus paradoxus resolved, and serial echocardiograms revealed a decrease in effusion. The patient was discharged home with instructions to follow up in 2 weeks with a repeat echocardiogram.
The patient, however, presented to the emergency room 10 days after discharge. He had been doing well for the first week after discharge, except for minimal fatigue. This was followed by low-grade fevers accompanied by inspiratory chest pain similar to his index admission, mild shortness of breath, and 2-pillow orthopnea.
Vitals signs revealed a heart rate of 110 bpm, blood pressure of 90/60 mm Hg, temperature of 102°F, and normal oxygen saturation. Jugular venous pressure was elevated at 10 cm and exhibited prominent X and deep Y descents (Friedreich sign) and Kussmaul sign (online-only Data Supplement Movie IV). The patient was in mild respiratory distress. A short 1/6 systolic murmur was noticed at the base of the heart. Pericardial friction rub and diastolic knock were not heard. Pulsus paradoxus was measured at 6 mm Hg. Investigations revealed the white blood cell count to be 14 600 cells/mL with a left shift. Cardiac enzymes and basic metabolic panel were unremarkable. The erythrocyte sedimentation rate was elevated at 55 mm.
An ECG revealed sinus tachycardia with 0.5 mm of ST elevation across precordial leads, without any PR-segment depression. The echocardiogram revealed normal left and right ventricular systolic function. Circumferential edematous thickening of the pericardium was appreciated.
Signs of constriction were elicited on transthoracic echocardiography (Figures 3 through 8⇓⇓⇓⇓⇓ and online-only Data Supplement Movies I through III). Transient constriction of acute pericarditis was diagnosed. Indomethacin 50 mg 3 times daily and colchicine 0.6 mg twice daily were started. The patient improved clinically, with partial resolution of constrictive physiology. He was discharged home and has been doing well on follow-up.
Videographic displays of Kussmaul sign are easily shown by aligning shadows across the venous pulse so as to display the waveforms. In the Table, the clinical signs are compared with their echocardiographic correlates, which in turn reflect the 2 pathophysiological mandates of constriction: exaggerated ventricular interdependence and dissociation between intracardiac and intrathoracic pressures.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/e683/DC1.