Gallium-67 citrate localization in the heart secondary to constrictive pericarditis with myocardial fibrosis

Scintigraphy has demonstrated gallium-67 accumulation within the heart in pericarditis and cardiomyopathies of various kinds. We present a case report of a 63-yr-old man with multisystem disease who showed extensive myocardial uptake of Ga-67 by scintigraphy. At autopsy, constrictive pericarditis with myocardial fibrosis was found. Gallium-67 localization has not been documented previously in myocardial fibrosis accompanying constrictive pericarditis.

Subacute constrictive pericarditis from Serratia marcescens bacteremia

A case report of subacute constrictive pericarditis associated with disseminated Serratia marcescens infection and bacteremia in a patient with chronic tubulointerstitial nephritis and uremia is described. Although not substantiated by clinical history, the renal pathologic features were similar to those of ethylene glycol-induced tubulointerstitial nephritis. The patient did not have a history of heroin addiction. The importance of predisposing factors such as uremia, invasive vascular procedures, tracheal intubation, peritoneal dialysis, and pericardiocentesis in Serratia infection in susceptible persons is discussed, as are possible roles of uremia, pericardiocentesis, and pericardiotomy in the pathogenesis of constrictive pericarditis in the present case.

Aetiology of chronic constrictive pericarditis

In a consecutive series of 32 cases of chronic constrictive pericarditis treated by pericardiectomy during the past 25 years, four were attributable to rheumatoid disease, two to trauma, one to sarcoidosis, and four, at a maximum, to tuberculosis. In the remaining 21 cases of undetermined aetiology there was no evidence of tuberculosis. It appears, therefore, that tuberculosis was not a common cause of chronic constrictive pericarditis during the period under review, which included the 1950s and early 1960s when tuberculosis was widespread.

Endomyocardial biopsy

Endomyocardial biopsy has been used more frequently over the past 10 years in an increasing number of centers in this country and abroad. When done by an experienced physician, it is as safe as routine cardiac catheterization. Although biopsy is not yet applicable in all cases of myocardial disease, many investigators have found this procedure valuable in specific circumstances, including cardiac allograft rejection, anthracycline-induced cardiomyopathy, and myocarditis. With this technique diagnoses can be made for various disorders including cardiac amyloidosis, sarcoidosis, hemochromatosis, and endomyocardial fibrosis. Although helpful in detecting an unsuspected condition or in formulating prognosis in some patients, biopsy is not diagnostically specific in patients with dilated or hypertrophic cardiomyopathy, because these diseases have no completely pathognomonic features under current examination methods. The proper practice of endomyocardial biopsy requires both technical proficiency and expert pathologic interpretation. As a research tool, biopsy will continue to yield new knowledge about myocardial disease and its treatment.

Constrictive epicarditis as a cause of delayed or absent response to pericardiectomy: a clinicopathological study

It is widely held that constrictive pericarditis is curable by pericardiectomy, and failure to respond reflects an underlying myocardial disease. Fibrous epicarditis could account for residual cardiac constriction, and delayed hemodynamic response in some patients is an alternative explanation. To examine this, we studied the 12 consecutive patients with otherwise normal hearts treated with extensive pericardiectomy for constrictive pericarditis over the past 7 years. Three hemodynamic responses to pericardiectomy were observed: (1) rapid response, where central venous pressure (CVP) fell below 10 cm H2O by 24 hours in two patients; (2) delayed response, where CVP fell below 10 cm H2O by 48 hours in six patients; and (3) no response of CVP in four patients. The CVPs remained critically elevated (greater than 25 cm H2O) in three patients with delayed response until a sclerotic epicardial peel was resected. Another patient whose CVP of 30 cm H2O showed no change after parietal pericardiectomy was thought to have amyloid cardiomyopathy but instead at autopsy had constrictive epicardial sclerosis not recognized at parietal pericardiectomy. Histologic features of parietal pericardium had no correlation with hemodynamic response, whereas epicardial histology did correlate with hemodynamic response in four patients. The data showed a spectrum of postpericardiectomy delayed hemodynamic responses, which in some patients may be due to a slowly resolving or fixed component of fibrous epicarditis that may be clinically misconstrued as a cardiomyopathy. Interruption of visceral pericardial tissue may be as important as resection of the parietal pericardium in patients with epicardial sclerosis.

Diseases of the pericardium: morphologic study of surgical specimens from 35 patients

The gross and microscopic features of 35 pericardial surgical specimens are described. Nineteen specimens were associated with pericardial effusion, and microscopic study showed nonspecific fibrous changes in eight, tuberculous granulomatous inflammation in four, purulent inflammation in four, neoplastic involvement in four, and siderosis of the pericardium in one. Twelve of these were clinically associated with constriction. Calcification of the pericardium was the predominant feature in eight of the specimens. None of these eight specimens showed features of tuberculous infection. Of the remaining four, two showed chronic fibrinous changes and the other two showed granulomatous inflammation of presumed tuberculous origin. Four pericardial cysts were seen. Pericardial disease was an incidental finding in 13 instances (37 per cent), suggesting the frequent underdiagnosis and asymptomatic nature of disease of the pericardium. The associations of infections, trauma, hemopericardium, and collagen diseases and pericardial diseases are discussed.

Rheumatic constrictive pericarditis. A case report and review of the literature

A case of calcific constrictive pericarditis in a young White woman with a convincing history of previous acute rheumatic fever complicated by a possible valvular lesion is presented. Cardiac catheterization confirmed the suspicion of significant cardiac compression. Successful pericardiectomy was carried out, but microscopical examination of the excised pericardium failed to demonstrate a cause. In view of the strong past history of acute rheumatic fever and mild mitral insufficiency demonstrated at cardiac catheterization, the author proposes that the calcific constrictive pericarditis was of rheumatic origin. A review of the literature on the association between rheumatic infection and constrictive pericarditis follows.

Genesis of pericardial knock in constrictive pericarditis

A pericardial knock is a common finding in constrictive pericarditis. However, its origin has been uncertain. One hypothesis suggests that it is due to sudden deceleration of ventricular filling. To validate this hypothesis, left ventriculograms, phonocardiograms and external pulse recordings were obtained in seven patients with hemodynamic and pathologic findings of constrictive pericarditis and in seven normal subjects. Left ventriculographic silhouettes were digitized and left ventricular volumes were calculated by computer at 16 ms intervals. Curves of left ventricular volume versus diastolic filling time were constructed for each patient. Pericardial knock was recognized as an early high frequency sound recorded between 90 to 120 ms after the aortic closing sound and occurring at the trough of the Y descent of the jugular venous pressure tracing. The timing of the pericardial knock in five patients with constrictive pericarditis corresponded to a sudden and premature plateau of the diastolic left ventricular volume curve representing 85 +/- 4 percent (mean +/- standard deviation) of ventricular filling. The diastolic plateau was missing in two patients with constrictive pericarditis who had no pericardial knock. In these cases, the rate of ventricular filling was faster than normal in the first 20 percent of diastole. Thus, this study related pericardial knock to an abrupt plateau inthe diastolic left ventricular volume curve, supporting the view that sudden cessatin of ventricular filling generates the pericardial knock of constrictive pericarditis. Two mechanisms are proposed by which the filling plateau may produce the knock, and it is postulated that both ventricles may participate in the knock phenomenon.

Cholesterol pericarditis terminating as constrictive calcific pericarditis. Follow-up study of patient with 40 year history of disease

This is a follow-up report of a patient with idiopathic cholesterol pericarditis (previously described in this Journal in 1961). The patient had had recurrent pericardial effusions since 1939, and died with calcific constrictive pericarditis some 40 years later. In the interim, the patient had an extended period (17 years) of symptomatic relief after pericardiotomy in 1958.

Echocardiographic diagnosis of pericardial disease

Echocardiograms were performed in 11 patients with constrictive pericarditis or effusive-constrictive pericarditis confirmed by cardiac catheterization and pericardiectomy. Three echocardiographic patterns of pericardial disease were noted and were related to three types of pericardial pathology. Parallel moving echoes separated by a clear space were reflected from chronically fibrosed and thickened pericardium without associated pericardial exudate. Effusive-constrictive pericarditis or subacute wet pericarditis was characterized on the echocardiogram by a posterior echo-free space representing the liquid pericardial effusion and multiple ultrasonic lines from the thickened visceral pericardium. Subacute dry pericarditis was associated with numerous ultrasonic signals filling the space between the visceral pericardium and the relatively flat parietal pericardium. These ultrasonic signals were reflected from coagulated pericardial exudate which was adherent both to the parietal pericardium and the visceral pericardium. Parallel moving echoes or dense bands of echoes were reflected from either or both thickened visceral and parietal pericardium.

Whipple's disease involving the pericardium: Pathological confirmation during life

Cardiac involvement in Whipple's disease has been a frequent autopsy finding but is rarely recognized clinically. We report here a patient, a 63-year-old man, in whom Whipple's disease was diagnosed in 1974, based on a seven-year history of arthralgia, one-year history of weight loss and steatorrhea, and diagnostic small bowel biopsy. Despite complete regression of all joint and bowel symptoms following a prolonged course of tetracycline therapy, the patient developed incapacitating congestive heart failure and signs of constrictive pericarditis, for which a thoracotomy and pericardectomy was performed. Histologic examination revealed fibrous pericarditis with mononuclear infiltrates, including PAS-positive histiocytes. The characteristic bacilliform bodies were identified by electron microscopy in the resected pericardium. This to our knowledge is the first such demonstration during life of Whipple's disease involving the heart.

Proteins of ascitic fluid in constrictive pericarditis

A patient with chronic calcific pericarditis, hepatic congestion, and fibrosis had massive ascites with a protein concentration of 5.1 g/100 ml. This fluid was in all likelihood largely derived from hepatic interstitial fluid. The ascites-serum concentration ratio for several protein species and molecular exclusion chromatography of these fluids suggested two processes may be involved in the transfer of protein from serum to ascites, namely bulk transfer of all species and molecular sieving.

Endocarditis with myocardial abscesses and pericarditis in an adult: group B Streptococcus as a cause

Group B beta-hemolytic Streptococcus, S agalactiae, is an uncommon cause of endocarditis in adults. We present the clinical, laboratory, and postmortem findings of an adult patient with group B streptococcal endocarditis and major arterial emboli. What to our knowledge are previously unreported features are purulent pericarditis and myocardial abscesses. Twenty-five cases of endocarditis caused by group B Streptococcus that are reported in the literature are reviewed.