Recurrent Idiopathic Pleural Effusions: Do Consider Constricitve Pericarditis as a Cause

Abstract

SESSION TITLE: Fellow Case Report Slide: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 23, 2016 at 03:15 PM - 04:15 PM INTRODUCTION: We present a case of a healthy man presenting with recurrent dyspnea and no noted improvement after thoracentesis which led to further work up revealing constrictive pericarditis. CASE PRESENTATION: A 59 year old Caucasian male presents to hospital with recurrent dyspnea. He had initially presented with complaints of dyspnea and chest tightness after he had an episode of upper respiratory tract infection a week ago. When he had presented to the hospital he was noted to be in atrial fibrillation along with a left sided pleural effusion. Effusion was drained, he did not notice any improvement in his breathing so dyspnea was attributed to underlying conduction abnormalities and ablation was scheduled for following week. Echocardiogram revealed dys-synchronous ventricular septal motion probably secondary to conduction abnormality, mild left ventricular systolic dysfunction of 50%,small pericardial effusion.Pleural studies revealed pH 7.46, white blood cell count of 1070/mm3 with 38%neutrophils, 24%lymphocytes, 36%monocytes,red blood cells of 32000/mm3, protein 3 g/dl,lactate dehydrogenase(LDH) of 107 U/L(serum protein 7.6 g/dl,LDH 181 U/L). Pleural fluid cytology and cultures were negative. Trans-esophageal Echocardiogram on day of scheduled ablation revealed no irregular rhythm, increasing pericardial effusion and recurrent pleural effusion with continued symptoms.Physical exam was relevant for elevated JVD , distant heart sounds, regular rhythm, pericardial rub, decreased air entry on left lung base. Repeat thoracentesis was exudative. Further work up with cardiac catheterization revealed near equalization of diastolic pressures and findings suggestive of constriction. Patient underwent pericardiectomy with signs of immediate hemodynamic improvement. Surgical pathology revealed pericardium with dense fibrosis and organizing thrombus consistent with constrictive pericarditis. Left pleural biopsy was performed and no pathologic alteration was noted. DISCUSSION: We suspect viral pericarditis leading to pleural effusion as the most likely cause of his constrictive pericarditis. The treatment of constrictive pericarditis is surgical resection of the pericardium. CONCLUSIONS: Pleural effusions transudative or exudative are often associated with constrictive pericarditis. A high index of suspicion is needed in the diagnosis to avoid delay. Right heart catheterization is gold standard. Reference #1: A 43-Year-Old Man With a Large Recurrent Right-Sided Pleural Effusion Chest. 2000;117(4):1191-1194. DISCLOSURE: The following authors have nothing to disclose: Susheela Hadigal, Almotasembellah Aljaafareh, Divya Patel No Product/Research Disclosure Information