Late onset radiation-induced constrictive pericarditis and cardiomyopathy after radiotherapy: A case report

INTRODUCTION

Radiation-induced heart disease (RIHD) is a serious side effect of cancer treatment, including coronary artery disease, valvular cardiac dysfunction, cardiomyopathy, aortopathy, and chronic constrictive pericarditis. Herein, this case we present was diagnosed as radiation-induced constrictive pericarditis and cardiomyopathy by means of cardiac magnetic resonance (CMR) and transthoracic echocardiogram, finally confirmed by pathology after performing heart transplant operation.

CONCLUSIONS

This case supports a notion that RIHD often causes multiple heart impairment and CMR is helpful to diagnose cardiomyopathy after radiation.

Predictive factors for unfavorable outcomes of tuberculous pericarditis in human immunodeficiency virus-uninfected patients in an intermediate tuberculosis burden country

BACKGROUND

In areas where Mycobacterium tuberculosis is endemic, tuberculosis is known to be the most common cause of pericarditis. However, the difficulty in diagnosis may lead to late complications such as constrictive pericarditis and increased mortality. Therefore, identification of patients at a high risk for poor prognosis, and prompt initiation of treatment are important in the outcome of TB pericarditis. The aim of this study is to identify the predictive factors for unfavorable outcomes of TB pericarditis in HIV-uninfected persons in an intermediate tuberculosis burden country.

METHODS

A retrospective review of 87 cases of TB pericarditis diagnosed at a tertiary referral hospital in South Korea was performed. Clinical characteristics, treatment outcomes, complications during treatment, duration of treatment, and medication history were reviewed. Unfavorable outcome was defined as constrictive pericarditis identified on echocardiography performed 3 to 6 months after initial diagnosis of TB pericarditis, cardiac tamponade requiring emergency pericardiocentesis, or death. Predictive factors for unfavorable outcomes were identified.

RESULTS

Of the 87 patients, 44 (50.6%) had unfavorable outcomes; cardiac tamponade (n = 36), constrictive pericarditis (n = 18), and mortality (n = 4). 14 patients experienced both cardiac tamponade and constrictive pericarditis. During a 1 year out-patient clinic follow up, 4 patients required repeat pericardiocentesis and pericardiectomy was performed in 0 patients. In the multivariate analysis, patients with large amounts of pericardial effusion (P = .003), those with hypoalbuminemia (P = .011), and those without cardiovascular disease (P = .011) were found to have a higher risk of unfavorable outcomes.

CONCLUSION

HIV-uninfected patients with TB pericarditis are at a higher risk for unfavorable outcomes when presenting with low serum albumin, with large pericardial effusions, and without cardiovascular disease.

Angiosarcoma Causing Cardiac Constriction Late after Radiation Therapy for Breast Carcinoma

Therapeutic radiotherapy rarely causes sarcoma, and this occurs years after completion of the intended treatment. In treating breast carcinoma, careful planning in the application of modern radiotherapeutic techniques usually can shield the heart and pericardium. We report a rare case of angiosarcoma of the pericardium, which presented in a 41-year-old woman as constrictive pericarditis 8 years after irradiation for cancer of the left breast. To our knowledge, this is only the 2nd report of angiosarcoma of the pericardium after radiotherapy.

[Constrictive pericarditis as a serious and rare presentation of systemic lupus erythematosus: Report of one case]

Constrictive Pericarditis (CP) is an unusual disease. Its most common causes are idiopathic or secondary to cardiac surgery. Less frequently it is caused by connective tissue diseases. We report a 30 years old woman hospitalized due to progressive dyspnea, chest pain and signs of right sided heart failure. During her stay, a Systemic Lupus Erythematosus (SLE) was diagnosed. The echocardiogram suggested a CP and the diagnosis was confirmed by cardiac catheterization. Pericardiectomy was successfully performed. The biopsy confirmed a nonspecific chronic pericarditis, with extensive fibrosis and absence of caseating granulomas. The patient had a satisfactory recovery.

[Chronic constrictive pericarditis]

Chronic constrictive pericarditis is a rare condition characterized by an impairment of myocardial relaxation due to limitation by a rigid pericardium. It is most often associated with infection, thoracic radiotherapy and heart surgery. Clinical features are that of chronic heart failure, therefore non-specific and resulting in a delay of several years before diagnosis is made. The echocardiogram and heart catheterization are part of the initial work-up. Surgical treatment consisting in pericardiectomy can be curative if the disease is recognised early. This article makes use of a case report and review of the litterature to discuss the physiopathology, clinical features and management of chronic constrictive pericarditis.

Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis

BACKGROUND

Tuberculous pericarditis is associated with high morbidity and mortality even if antituberculosis therapy is administered. We evaluated the effects of adjunctive glucocorticoid therapy and Mycobacterium indicus pranii immunotherapy in patients with tuberculous pericarditis.

METHODS

Using a 2-by-2 factorial design, we randomly assigned 1400 adults with definite or probable tuberculous pericarditis to either prednisolone or placebo for 6 weeks and to either M. indicus pranii or placebo, administered in five injections over the course of 3 months. Two thirds of the participants had concomitant human immunodeficiency virus (HIV) infection. The primary efficacy outcome was a composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis.

RESULTS

There was no significant difference in the primary outcome between patients who received prednisolone and those who received placebo (23.8% and 24.5%, respectively; hazard ratio, 0.95; 95% confidence interval [CI], 0.77 to 1.18; P=0.66) or between those who received M. indicus pranii immunotherapy and those who received placebo (25.0% and 24.3%, respectively; hazard ratio, 1.03; 95% CI, 0.82 to 1.29; P=0.81). Prednisolone therapy, as compared with placebo, was associated with significant reductions in the incidence of constrictive pericarditis (4.4% vs. 7.8%; hazard ratio, 0.56; 95% CI, 0.36 to 0.87; P=0.009) and hospitalization (20.7% vs. 25.2%; hazard ratio, 0.79; 95% CI, 0.63 to 0.99; P=0.04). Both prednisolone and M. indicus pranii, each as compared with placebo, were associated with a significant increase in the incidence of cancer (1.8% vs. 0.6%; hazard ratio, 3.27; 95% CI, 1.07 to 10.03; P=0.03, and 1.8% vs. 0.5%; hazard ratio, 3.69; 95% CI, 1.03 to 13.24; P=0.03, respectively), owing mainly to an increase in HIV-associated cancer.

CONCLUSIONS

In patients with tuberculous pericarditis, neither prednisolone nor M. indicus pranii had a significant effect on the composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. (Funded by the Canadian Institutes of Health Research and others; IMPI ClinicalTrials.gov number, NCT00810849.).

Occult constrictive pericarditis

Four cases of occult pericardial constriction are presented. This condition is not uncommon, but needs high index of suspicion. Integration of detailed echocardiographic evaluation in a given patient with diseases known to cause pericardial involvement can clinch the diagnosis.

[Constrictive pericarditis: case report and review]

Constrictive pericarditis (CP) is a common disease with difficult diagnosis. We report a well-documented case of CP with extended pericardial calcification treated by total pericardiectomy. A brief review of symptoms and signs of CP is presented, as well as additional examination allowing the diagnosis to be confirmed. The differential diagnosis with restictive cardiomyopathy is also discussed.

[Constrictive pericarditis as complication of viral respiratory infection]

A 24 year-old man with 3-months medical history of recurrent respiratory infections and pericardial effusion, despite treatment with nonsteroid anti-inflammatory drugs, was admitted to the hospital with dyspnea on exertion. On admission he presented the symptoms of right heart insufficiency. Computed tomography of the chest demonstrated a thickened pericardium. Echocardiographic examination and right heart catheterisation established the diagnosis of constrictive pericarditis. Serologic tests suggested viral aetiology. The patient was referred to cardiothoracic surgery, partial pericardiectomy was performed with marked haemodynamic improvement.

Constrictive pericarditis treated by surgery

We reviewed the records of 45 patients (mean age, 46.6 ± 14.9 yr; range, 21-84 yr) with a diagnosis of constrictive pericarditis who had undergone pericardiectomy from 1994 through 2006. Preoperatively, 2 of the patients (4.4%) were in New York Heart Association (NYHA) functional class I, 20 (44.4%) in class II, 22 (48.9%) in class III, and 1 (2.2%) in class IV. Pericardial calcification was detected in 20% of plain chest radiographs. Constrictive pericarditis was caused by tuberculosis in 22.2%, chronic renal failure in 8.9%, a history of sternotomy in 4.4%, and malignancy in 4.4%. The cause was idiopathic in 60% of the patients. Low-output state was the most common postoperative problem (22.2%). The mean follow-up period was 40 ± 18 months (range, 3-144 mo). Three months postoperatively, only 1 of 43 available patients (2.3%) was in NYHA class III, while the rest were in class I (36 patients; 83.7%) or II (6 patients; 14%). The overall mortality rate was 4.4%: 1 patient with tuberculosis died of respiratory insufficiency while hospitalized, and 1 died of metastatic adenocarcinoma during follow-up. Our results show that pericardiectomy remains an effective procedure in the treatment of constrictive pericarditis. Tuberculosis is still an important cause of constrictive pericarditis in Iran, despite intensive vaccination and use of antitubercular drugs.

Familial Mediteranean fever with protein-losing enteropathy due to constrictive pericarditis

BACKGROUND

Constrictive pericarditis (CP) represents a rare cause of protein-losing enteropathy (PLE) resulting from intestinal lymphangiectasia (IL). In this report, we describe an 8-year-old Turkish boy with IL and PLE secondary to CP.

METHODS

The boy was introduced to our clinic due to bilateral pretibial edema and swelling of the eyelids caused by hypoproteinemia. Physical examination revealed a distended right jugular vein. Laboratory investigation revealed PLE with fecal concentration of alpha-1 antitripsin of 4.87 mg/g. Histopathologic examination of random biopsies obtained from the duodenum revealed markedly dilated lymphatics compatible with IL. Constrictive pericarditis was diagnosed by tagged cine cardiac magnetic resonance imaging.

RESULTS

Pericardiectomy was performed for the patient. Genetic analysis was done and heterozygous mutation E148Q was detected as a disease-causing Mediterranean fever (MEFV) mutation. Colchicine was started after the operation. Six months after the initiation of regular colchicine therapy, echocardiography revealed disappearance of CP.

CONCLUSION

This is the first reported case of PLE with a distended right jugular vein due to CP secondary to familial Mediterranean fever associated with E148Q heterozygosity in the MEFV gene.

[The concomitance of pericarditis constrictiva in patient with Silver-Russell syndrome, primary hyperparathyroidism and oncologic history: causal coincidence or pathogenetic sequence?]

The most common cause of calcific pericarditis is idiopathic. We report a case of a 24 year-old woman with Silver-Russell syndrome, history of Wilms' tumour in childhood, constrictive pericarditis and primary hyperparathyroidism. We analyse pathologic mechanisms of disseminated calcification and possible genetic factors that may contribute to aetiology and clinical presentation of calcific pericarditis.

[Diagnosis and effective surgical treatment of constrictive pericarditis]

Constrictive pericarditis is a rare and severe disease. Timely and correct differential diagnosis of this pathology facilitates choice of necessary tactics of treatment and thus improve prognosis and quality of life. In this paper we present clinical case report of a patient with constrictive pericarditis. The disease was diagnosed on the basis of clinical picture, data of X-ray and echocardiographic investigation, and confirmed by multispiral computed tomography (MSCT). The patient was subjected to pericardioectomy with positive clinical effect and results of repeated echocardiography and MSCT.

Medical therapy of pericardial diseases: part II: Noninfectious pericarditis, pericardial effusion and constrictive pericarditis

The treatment of pericardial diseases is largely empirical because of the relative lack of randomized trials compared with other cardiovascular diseases. The main forms of pericardial diseases that can be encountered in the clinical setting include acute and recurrent pericarditis, pericardial effusion with or without cardiac tamponade, and constrictive pericarditis. Medical treatment should be targeted at the cause as much as possible. In this article, the therapy of more common forms of noninfectious pericarditis (pericarditis in systemic autoimmune diseases and neoplastic pericardial disease), pericardial effusion, and constrictive pericarditis is reviewed.

Segmental diastolic compression of venous and arterial conduits post coronary artery bypass surgery

In a case of constrictive pericarditis post coronary artery bypass surgery we describe the diastolic compression of venous and arterial conduits and the timing of compression, as demonstrated during angiography, before and after pericardiectomy. In conclusion, angiographic demonstration of conduit compression is only suggestive of constriction, and consideration of the timing of compression during diastole should be a more specific sign.

A rapid evolution from effusive-constrictive to constrictive pericarditis

We present a case of a 69-year-old woman with constrictive pericarditis preceded by effusive-constrictive pericarditis. Echocardiography on admission revealed a mild pericardial effusion, pericardial thickening and a constrictive physiology in the absence of RV pressure/volume overload suggesting effusive-constrictive pericarditis. Echocardiographic follow-up showed gradual disappearance of the effusion within one month and an important thickening of the visceral and parietal pericardium up to 9 mm. Respiratory variation of the mitral and tricuspid inflow, prominent diastolic septum shift and high mitral annular TDI-velocities were indicative of constrictive pericarditis. Subsequent left/right heart catheterisation 3 months after the initial diagnosis confirmed constrictive pericarditis with elevated diastolic pressures equalized in the four heart chambers, square root sign, respiratory discordant change of the left and right systolic pressures and an inspiratory increase of the right atrial pressure. The patient remained symptomatic under treatment with aspirin and diuretics. A parietal and visceral pericardectomy was successfully performed with a favourable clinical evolution.