Extremely high ferritin level after an acute myocardial infarction in an end stage renal disease patient

Abstract

We present here a case of an asymptomatic end-stage renal disease (ESRD) patient, who had an unexplained persistent mild leukocytosis in the setting of an extremely high ferritin level (8,997 ng/ml; reference range: 12 - 300 ng/ml) 3 weeks after she suffered from a myocardial infarction (MI). Infection as the cause of these laboratory abnormalities was ruled out. A week later, the patient was noted to have asymptomatic hypotension (100/60 mmHg; her baseline blood pressure was 120/70 mmHg) during a maintenance hemodialysis session. An echocardiography revealed an interval development of moderate pericardial effusion when compared to her previous echocardiography 4 weeks before. In the setting of a recent MI with other laboratory markers suggesting an ongoing inflammatory process, a tentative diagnosis of Dressler's syndrome was made. A pericardial tap yielded exudative (bloody) fluid, thus, confirming our suspicion. Dressler's syndrome results from an inflammation of the pericardium as a consequence of an underlying autoimmune process few weeks to months after a myocardial infarction or post-cardiac surgery. Although it typically presents with pleuritic chest pain, fever, leukocytosis, and a friction rub; our case illustrates that the initial presentation may be asymptomatic in ESRD patients. For the same reason, it is likely an under-recognized entity in such patients. An unexplained elevated ferritin in an ESRD patient with recent history of MI should prompt an investigation for Dressler's syndrome. In those with associated significant pericardial effusion, daily HD should be initiated and anticoagulation should be avoided. Unlike other ESRD associated pericarditis, steroids and NSAIDs should be avoided in Dressler's syndrome as they may hamper cardiac remodeling in the immediate post-MI period. Colchicine may offer some benefit in patients with associated chest pain. For those failing medical management or manifesting overt signs of tamponade, surgical drainage should be preferred.