Pericardial Disease - Cases

1331665 - Constrictive Tuberculous Pericarditis

Friday, January 27, 2023

7:00 AM – 7:50 AM

Location: Pacific Jewel

Presenting Author(s)

LH

Logan P. Haug, MD

Resident
Mayo Clinic
Phoenix, Arizona, United States

Primary Author(s)

LH

Logan P. Haug, MD

Resident
Mayo Clinic
Phoenix, Arizona, United States

Co-Author(s)

CJ

Clinton Jokerst, MD

Staff Radiologist
Mayo Clinic, United States

Description of Clinical Presentation: A 32-year-old male without significant past medical history who had immigrated from Africa five years prior presented to the ED with shortness of breath, pleuritic chest pain, fever, and lower extremity edema for one month. Vitals were normal aside from mild tachycardia and tachypnea. Complete blood count was notable only for mild anemia, white blood cell count was normal. ESR was mildly elevated with markedly elevated CRP. The remainder of the labs were notable for elevated aminotransferases, decreased serum albumin, and elevated BNP. CT chest and cardiac MR were notable for pericardial thickening and QuantiFERON was subsequently positive. Overall, findings were compatible with constrictive tuberculous pericarditis.

Diagnostic Techniques and Their Most Important Findings: CT C/A/P with IV contrast revealed right hilar, precarinal, aortopulmonary window, and prevascular adenopathy. Pericardial thickening and IVC dilatation with hepatomegaly were also noted. A transthoracic echocardiogram was performed and notable for pericardial thickening and diminished biventricular function with LVEF of 30%. Cardiac MR W/WO contrast, performed for further evaluation, demonstrated pronounced pericardial thickening measuring 24 mm with associated enhancement and minimal effusion. Biventricular dysfunction (LVEF of 24% and RVEF of 20%), IVC dilatation, moderate bilateral pleural effusions, and enhancing precarinal, right hilar, and right anterior diaphragmatic adenopathy were also noted. Free breathing images were limited by shallow breathing but did suggest respirophasic septal flattening without definitive septal bounce.

Learning Points from this Case:

Pericardial thickening can be secondary to multiple etiologies including malignancy (breast, lung, and lymphoma), infectious or idiopathic pericarditis, prior pericardiotomy, uremic pericarditis, prior radiation therapy, connective tissue disorders such as rheumatoid arthritis and systemic lupus erythematosus, and sarcoidosis. Massive pericardial thickening is most suggestive of malignancy or infection, particularly bacterial or fungal etiologies.

Of patients with pulmonary (TB), 1-2 % will progress to pericardial involvement. Of those with pericardial involvement greater than 50% develop constrictive features, and 14-40% will succumb to the disease as a result.

Cardiac MR should be ordered when there are inconclusive echocardiographic findings, concern for constriction, atypical presentation, or concomitant thoracic disease. Cardiac MR is the most sensitive test for identifying constriction and detecting pericardial inflammation/thickening. Pericardial thickening >4 mm with signs and symptoms of right heart failure is highly specific for constriction. Constriction most commonly involves the right heart due to its comparatively thinner ventricular wall and when chronic, can lead to a conical deformity of the ventricles. Diastolic interventricular septal flattening is also sensitive (62-81%) and specific (93-100%) for constriction with respirophasic variation in septal motion being pathognomonic.