A 39-year-old patient with no prior medical visits presents with cardiac tamponade and undergoes urgent pericardiocentesis. He is from sub-Saharan Africa and has never been seen by a physician before—reports feeling progressively ill for the past month and brought to the hospital after syncopal episode today. Fluid analysis is performed and listed below:
The most likely etiology for the effusion would be:
Tuberculous pericarditis. The patient presents with acute tuberculous pericarditis with large exudative effusion. Indolence of the effusion is likely over months; however, the salient findings in the fluid analysis are the elevated interferon gamma, ADA, and normal peripheral white blood cell count with pericardial lymphocyte predominance. The presence of interferon gamma elevation had a 92% sensitivity, 100% specificity, and 100% positive predictive value for tuberculous pericarditis. ADA was also linked to tuberculous pericarditis; however, it was not as sensitive or specific (87%/92%).
Although Answers b and c are epidemiologically possible, the fluid analysis is not suggestive of either. Pericardial biopsy (Answer d) is incorrect as tuberculous pericarditis can be defined by the interferon gamma and ADA elevation. Also Acid-Fast Bacilli (AFB) staining will reveal AFB + organisms confirming diagnosis. Biopsy should be reserved for patients with unrevealing fluid analysis who are still symptomatic and require further diagnostic testing to make a diagnosis.
A 47-year-old man with constrictive pericarditis is undergoing an echocardiogram for follow-up. The sonographer asks you to explain the difference between the annulus reversus and annulus paradoxus phenomena.
Which of the following statements is correct?
Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (E’ septal > E’ lateral) and annulus paradoxus refers to inverse correlation of E/E’ and LV end-diastolic pressure. The annulus reversus phenomenon describes a reversal of mitral lateral and septal tissue Doppler velocity. Normally, E’ lateral > E’ septal; however, in constrictive pericarditis it is postulated that tethering of the free wall prevents longitudinal motion of the annulus at the lateral border, thus decreasing the lateral E’ and the septal E’ concurrently is mildly exaggerated. The annulus paradoxus phenomenon was initially described after data looking at the correlation between the E/E’ ratio and pulmonary capillary wedge pressure were established. In a small subset of patients with constrictive pericarditis, inversion of the correlation between E/E’ and PCWP was noted, and named annulus paradoxus.
A 51-year-old male patient is admitted to the hospital with anasarca and progressive dyspnea and functional limitation. He has a prior history of coronary artery bypass grafting and post-pericardiotomy syndrome with relapsing pericarditis that has likely advanced to constrictive physiology (despite slow taper steroid therapy), given his presenting symptoms and physical examination findings. During the admission he is aggressively diuresed with IV diuretics with improvement in his renal and liver function, as well as symptom improvement (edema and dyspnea). He is unable to go for a magnetic resonance imaging (MRI) for further assessment (prior metallic implant in his spine for scoliosis) and his echocardiogram images are technically difficult due to his distorted spine and prior cardiac surgery. He is referred for dual transducer cardiac catheterization for hemodynamic evaluation of right- and left-sided pressures as part of his diagnostic workup. The catheterization laboratory team begins the procedure and calls you to discuss the case. They note a sinus rhythm at 90 bpm with occasional premature ventricular contraction and a central venous pressure of 4 mmHg and nonelevated end-diastolic pressures at the beginning of the study (due to recent diuresis); they are unable to elucidate diastolic equalization of pressures, significant “dip and plateau,” or respiratory discordance of the ventricular pressure waveforms.
A potential mechanism for the discordant catheterization findings would be:
Lack of preload due to overdiuresis. Volume loading is required to elucidate the diagnostic findings described above. Constrictive pericarditis is a preload-dependent condition and with overdiuresis and low central venous pressure, the hemodynamic findings of elevated and equal end-diastolic ventricular pressure waveforms as well as respiratory discordance of the LV/RV waveforms are not seen. Often in these cases, the patient is given a bolus of 1 to 2 L of normal saline to increase the RA pressure >12 to 15 mmHg and the study is performed once they are adequately volume loaded. Of note, in cases of atrial fibrillation, the patient may require a temporary venous pacemaker to regularize the rhythm for analysis purposes.
A 32-year-old white man presented initially with low-grade fever, cough, and pleuritic chest pain. He was found on ECG to have diffuse ST-segment elevation. A transthoracic echocardiogram (TTE) revealed a large pericardial effusion, and serologies were positive for coxsackievirus B infection. He was diagnosed with acute viral pericarditis and treated with indomethacin. He returns 4 weeks later for follow-up and states that he no longer has any pain, but he notes some mild ankle swelling. His ECG is normal. A repeat TTE shows resolution of the effusion but new findings consistent with mild constriction.
What is the next step in managing this patient?
Reassure the patient and observe him over the next 3 months for worsening of symptoms. The natural history of acute viral or idiopathic pericarditis is usually short and self-limited. Occasionally, mild forms of constriction may develop weeks after the initial event, but they usually resolve without any specific treatment. No further treatment is indicated unless he becomes more symptomatic or develops signs of cardiac tamponade.
A 45-year-old woman with a history of treated carcinoma of the breast presents to the local emergency department with a few days of severe chest pain. In the emergency department, she appears ill and pale and in moderate discomfort. Her BP is 135/60 mmHg; her respiratory rate is 24 breaths per minute; her HR is 82 bpm; and her temperature is 100.8°F. The resident on call reads her chest X-ray (CXR) as unremarkable. Her ECG is shown in Figure below.
What is the most reasonable next step?
Give a nonsteroidal anti-inflammatory medication. The clinical presentation of a few days of severe chest pain does not favor an acute MI. Furthermore, the ECG tracing supports the diagnosis of pericarditis. Therefore, cardiac catheterization and thrombolytics are not appropriate. The only reasonable answer is to start the patient on anti-inflammatory medications and obtain a TTE to rule out pericardial effusion.
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