Cardiology>>>>>Pulmonary Hypertension And Pericardium
Question 11#

You are reviewing a 42-year-old man in the outpatient clinic who is under follow-up for recurrent troublesome attacks of acute pericarditis. He has had 16 episodes of pericarditis which initially followed a viral illness. No underlying systemic cause has been found despite extensive investigations. The episodes are associated with small- to moderate-sized pericardial effusions. Initially, the episodes respond well to systemic steroids; however, he has troublesome steroid side effects. On weaning the steroids with appropriate colchicine cover, the episodes recur.

What is the best option with regard to management?

a. Plan to continue steroids long term at a lower dose as dual therapy with colchicine; appropriate bone protection should be given
b. Leave him off treatment and advise him to return immediately to the ED for early pericardiocentesis with topical high-dose steroid administration if his symptoms recur
c. Liaise with the rheumatological team regarding administration of immunosuppressant therapy as the most likely underlying pathological process is one of autoimmunity
d. Refer to cardiothoracic surgeons for consideration of total pericardiectomy
e. Continue to manage episodes with steroids and colchicine and monitor with annual echocardiograms for development of constrictive pericarditis

Correct Answer is D


This is a case of idiopathic pericarditis with characteristic recurrences on steroid withdrawal. Surgical pericardiectomy has been shown to alleviate the disorder and should be considered in cases of troublesome recurrent disease. There is a risk of failure to resolve symptoms if there is residual pericardial tissue postoperatively. In addition, recurrent disease can occur in the visceral pericardium, which cannot be stripped surgically.