Another simple pericarditis?

ABSTRACT

Background: A 19-year-old gentleman, with past history of sinusitis, aseptic meningitis upon birth & subsequent epilepsy, came back from the UK presenting with fever, sore throat, chills with myalgia, as well as pleuritic chest pain. Case COVID-19 was ruled out. Despite appropriate medications, his chest pain worsened together with epigastric pain. Fever persisted. Urgent CT was arranged for him showing findings suspicious of pericarditis. Serial ECG after admission revealed the classical findings compatible with pericarditis. He was taken over to CCU with treatment for pericarditis started. Unfortunately, despite empirical broad spectrum antibiotics & anti-inflammatories, his symptoms worsened with borderline blood pressure, increasing tachypnoea & persistent fever. Blood tests showed sky high white cell count up to 50 with neutrophil predominance. Serial echocardiograms showed a gradual increase in posteriorly-loculated pericardial effusion with fibrin, with striking findings of constriction physiology. Significant respirophasic changes in mitral & tricuspid inflow were demonstrated. Right-sided cardiac chambers were not collapsed, rather, the RA & the IVC were dilated. CT was repeated for deteriorating hemodynamics showing a rim-enhancing pericardial effuision. Decision making In view of the constrictive physiology demonstrated in echocardiograms, surgical intervention was deemed necessary for the patient & he was sent immediately to Queen Elizabeth Hospital Cardiothoracic Surgery team for emergency surgery. Conclusion: The classical teaching of constrictive pericarditis describes patients with prior insult to the pericardium such as surgery, previous tuberculosis infection, prior radiotherapy exposure, etc, such that the pericardium is calcified as a cage hindering the expansion of the heart. However, with the presence of purulent and fibrin-rich effusion, constrictive physiology can become evident and life-thereatening (Effusive-constrictive pericarditis) as well.