REVIEW ARTICLE
Difficulties in diagnosing chronic constrictive pericarditis
I.
Vasile, M. Negulescu, G. Florescu, R. Ionescu, S. Berbecaru
This presentation calls attention to the many problems involved in the positive, aetiological and differential diagnosis of chronic constrictive pencarditis. We mention the difficulties in aetiological diagnosis in the absence of an episode of acute pericarditis in the past medical history and the dinical findings similar to vascular decompensated cirrhosis or idiopathic restrictive cardiomyopathy. ECG and two-dimensional echocardiography do not have an important role in diagnosis, and in the absence of computed tomography and magnetic resonance imaging, chest radiography, especally a lateral view, could establish the diagnosis. A delay in diagnosis creates difficulties in the surgical treatment, but this treatment improves the patient's condition in the long term more than the short term. (Neth HeartJ2004;12:534-6.)
Keywords: chronic constnctive pericarditis, differential diagnosis, pericardiectomy Chronic constrictive pericarditis occurs when the Ohealing of an acute serum-fibrinous pericarditis or chronic pericardial effiusion is followed by obliteration of the pericardial space with fibrous tissue. In some reports the most frequent aetiology was tuberculosis, but in the last decade tuberculosis has been found to be a very rare cause in the US. Chronic constrictive pericarditis can also follow a purulent infection, thoracic trauma, all kinds ofcardiac surgery, radiation therapy to the mediastinum, 1. Vasilh M. NeguIhscu G. FRorscu R. Ionescu S. Berbecamu University of Medicine Craiova, Municipal Hospital Craiova, Romania
Correspondence to: A. Cufteac Frankenslag 406, 2582 JC The Hague E-mail: [email protected]
534
'Filantropia'.
histoplasmosis infection, malignant neoplasm, acute viral pericarditis, rheumatoid arthritis, systemic lupus erythematosus, and can occur in uraemic patients with chronic renal failure who require chronic dialysis. In many patients the cause of constrictive pericarditis is unknown and in these patients an asymptomatic or forgotten episode of idiopathic or viral pericarditis could be the starting process. Difficulties in clinical diagnosis of chronic constrictive pericarditis are multiple, especially in patients with no history of acute pericarditis who present to the medical clinic with physical and functional signs of right congestive heart failure and more pronounced ascites then peripheral oedema. We think it will be useful to consider a case that involves many problems for positive, aetiological and differential diagnosis, starting from poor data from the past medical history and the physical examination. We present a 65-year-old woman hospitalised in our medical clinic for dyspnoea at rest, palpitations and abdominal distension. From the history we found that the current disease had had an insidious onset 20 years previously with rapid and irregular palpitations. The diagnosis of atrial fibrillation was made and outpatient treatment with digitalis was recommended. Over the last ten years, she complained ofprogressive dyspnoea of effort, an ache in the right hypochondrium and oedema of the lower extremities, for which she was hospitalised in several medical clinics. We note the absence of significant findings for the present illness in the past medical history. Physical examination revealed an asthenic body build, cyanosis ofthe lips and nail beds, osteoarthritis, muscular hyperkinesia and hypotonia, lung resonance diminished at both bases, right pleural rub, blood pressure 120/80 mmHg, pulse 64 beats/min and irregular, totally irregular heart sounds, abdominal swelling with shifting dullness, with upper concavity, a significant amount of ascites fluid, abdominal wall collaterals, hepatomegaly with 14 cm prehepatic diameter, with abdominal-jugular reflux, jugular venous distension, first-degree splenomegaly and elevation of systemic venous pressure.
Ne54erlands Heart Journal, Vohlme 12, Number 12, December 2004
Difficulties in diagnosing chronic constrictive pericarditis
Figure 1.
Routine blood and biochemical investigations were normal, with normal liver function tests, except for mild anaemia (Hb 9.8 g%, Ht 26.7%). Ascites fluid contained a small number of cells, protein
Difficulties in diagnosing chronic constrictive pericarditis
I.
Vasile, M. Negulescu, G. Florescu, R. Ionescu, S. Berbecaru
This presentation calls attention to the many problems involved in the positive, aetiological and differential diagnosis of chronic constrictive pencarditis. We mention the difficulties in aetiological diagnosis in the absence of an episode of acute pericarditis in the past medical history and the dinical findings similar to vascular decompensated cirrhosis or idiopathic restrictive cardiomyopathy. ECG and two-dimensional echocardiography do not have an important role in diagnosis, and in the absence of computed tomography and magnetic resonance imaging, chest radiography, especally a lateral view, could establish the diagnosis. A delay in diagnosis creates difficulties in the surgical treatment, but this treatment improves the patient's condition in the long term more than the short term. (Neth HeartJ2004;12:534-6.)
Keywords: chronic constnctive pericarditis, differential diagnosis, pericardiectomy Chronic constrictive pericarditis occurs when the Ohealing of an acute serum-fibrinous pericarditis or chronic pericardial effiusion is followed by obliteration of the pericardial space with fibrous tissue. In some reports the most frequent aetiology was tuberculosis, but in the last decade tuberculosis has been found to be a very rare cause in the US. Chronic constrictive pericarditis can also follow a purulent infection, thoracic trauma, all kinds ofcardiac surgery, radiation therapy to the mediastinum, 1. Vasilh M. NeguIhscu G. FRorscu R. Ionescu S. Berbecamu University of Medicine Craiova, Municipal Hospital Craiova, Romania
Correspondence to: A. Cufteac Frankenslag 406, 2582 JC The Hague E-mail: [email protected]
534
'Filantropia'.
histoplasmosis infection, malignant neoplasm, acute viral pericarditis, rheumatoid arthritis, systemic lupus erythematosus, and can occur in uraemic patients with chronic renal failure who require chronic dialysis. In many patients the cause of constrictive pericarditis is unknown and in these patients an asymptomatic or forgotten episode of idiopathic or viral pericarditis could be the starting process. Difficulties in clinical diagnosis of chronic constrictive pericarditis are multiple, especially in patients with no history of acute pericarditis who present to the medical clinic with physical and functional signs of right congestive heart failure and more pronounced ascites then peripheral oedema. We think it will be useful to consider a case that involves many problems for positive, aetiological and differential diagnosis, starting from poor data from the past medical history and the physical examination. We present a 65-year-old woman hospitalised in our medical clinic for dyspnoea at rest, palpitations and abdominal distension. From the history we found that the current disease had had an insidious onset 20 years previously with rapid and irregular palpitations. The diagnosis of atrial fibrillation was made and outpatient treatment with digitalis was recommended. Over the last ten years, she complained ofprogressive dyspnoea of effort, an ache in the right hypochondrium and oedema of the lower extremities, for which she was hospitalised in several medical clinics. We note the absence of significant findings for the present illness in the past medical history. Physical examination revealed an asthenic body build, cyanosis ofthe lips and nail beds, osteoarthritis, muscular hyperkinesia and hypotonia, lung resonance diminished at both bases, right pleural rub, blood pressure 120/80 mmHg, pulse 64 beats/min and irregular, totally irregular heart sounds, abdominal swelling with shifting dullness, with upper concavity, a significant amount of ascites fluid, abdominal wall collaterals, hepatomegaly with 14 cm prehepatic diameter, with abdominal-jugular reflux, jugular venous distension, first-degree splenomegaly and elevation of systemic venous pressure.
Ne54erlands Heart Journal, Vohlme 12, Number 12, December 2004
Difficulties in diagnosing chronic constrictive pericarditis
Figure 1.
Routine blood and biochemical investigations were normal, with normal liver function tests, except for mild anaemia (Hb 9.8 g%, Ht 26.7%). Ascites fluid contained a small number of cells, protein
