Quick Fire Cases
Juthipong Benjanuwattra, MD
Cardiology Fellow
University of Cincinnati Medical Center
Juthipong Benjanuwattra, MD
Cardiology Fellow
University of Cincinnati Medical Center
Jonathan D. Feazell, MD
Resident
University of Cincinnati Medical Center
Sara A. Dressman, MD
Resident
University of Cincinnati Medical Center
David M. Harris, MD
Associate Professor (Advisor)
University of Cincinnati
A 50-year-old female patient with relapsed Hodgkin’s lymphoma initially presented with bilateral pleural effusions and a large pericardial effusion necessitating pericardiocentesis and subsequent pericardial window. She underwent allogenic bone marrow transplant which was complicated by neutropenic fever and a prolonged hospitalization. A month later, she developed gradually worsening dyspnea, positional chest pain and recurrent bilateral pleural effusions requiring multiple thoracenteses. Given her history and symptomatology, there was concern for effusive constrictive physiology.
Diagnostic Techniques and Their Most Important Findings:
The transthoracic echocardiogram (TTE) showed significant respirophasic variation in the tricuspid inflow velocities (Fig 1A), the hepatic venous Doppler with inspiratory diastolic flow reversal and increased forward flow as well as a dilated vena cava and pleural effusions (Fig 1B). However, there was no variation in the mitral inflow velocities (Fig 1C). Annulus paradoxus was demonstrated on tissue Doppler (Fig 1D). Respirophasic septal shift was only subtle without clear diastolic shuddering. There was also moderate-severe aortic regurgitation with vena contracta of 5.5 mm, pressure half-time of 355 msec and holodiastolic flow reversal in the descending aorta (Fig 2A-C). LVEDV and LVESV were within normal limits.
Due to discrepancy in the TTE findings and the high clinical suspicion, CMR was obtained. The patient was intubated and ventilated for the study due to significant shortness of breath and anxiety. As illustrated in Figure 3, there was diffuse non-calcified pericardial thickening measuring 3.2 mm with extensive gadolinium enhancement and evidence of myocardial adhesions on tagged imaging. However, there was no evidence of diastolic septal bounce or respirophasic septal shift while the patient was intubated. Aortic regurgitant fraction was 26%. Invasive hemodynamic study was not performed due to patient’s preference.
Learning Points from this Case:
The CMR was integral in confirming the diagnosis for this patient. The classic signs for respirophasic variation in the mitral inflow and septal bounce were blunted due to the underlying hemodynamic consequences of aortic regurgitation, but the CMR clearly characterized a thickened pericardium with adhesions in a patient who had been medical optimized. Constrictive pericarditis is a cause of unexplained pleural effusion according to multiple case series. Taken together, constrictive pericarditis is an uncommon condition that is often overlooked due to its diagnostic difficulty, thus emphasizing the role of multimodality imaging including CMR.
