Localized epicarditis mimicking cardiac tumor

Effusive-constrictive pericarditis

Effusive-constrictive pericarditis (ECP) is an increasingly recognized clinical syndrome. It has been best characterized in patients with tamponade who continue to have elevated intracardiac pressure after the removal of pericardial fluid. The disorder is due to pericardial inflammation causing constriction in conjunction with the presence of pericardial fluid under pressure. The etiology is diverse with similar causes to constrictive pericarditis and the condition is more prevalent with certain etiologies such as tuberculous pericarditis. The diagnosis is most accurately made using simultaneous intrapericardial and right atrial pressure measurements with pericardiocentesis, although non-invasive Doppler hemodynamic assessment can assess residual hemodynamic findings of constriction following pericardiocentesis. The clinical presentation has considerable overlap with other pericardial syndromes and as yet there are no biomarkers or non-invasive findings that can accurately predict the condition. Identifying patients with ECP therefore requires a certain index of clinical suspicion at the outset, and in practice, a proportion of patients may be identified once there is objective evidence for persistent atrial pressure elevation after pericardiocentesis. Although a significant number of patients will require pericardiectomy, a proportion of patients have a predominantly inflammatory and reversible pericardial reaction and may improve with the treatment of the underlying cause and the use of anti-inflammatory medications. Patients should therefore be observed for the improvement on these treatments for a period, whenever possible, before advocating pericardiectomy. Imaging modalities identifying ongoing pericardial inflammation such as contrast-enhanced magnetic resonance imaging or nuclear imaging may identify those subsets more likely to respond to medical therapies. Pericardiectomy, if necessary, requires removal of the visceral pericardium.

Nonconstrictive epicarditis mimicking a cardiac mass in a 71-year-old Caucasian man: a case report and review of the literature

Introduction

Isolated cases of epicarditis are rare. Thus far, all have occurred with constrictive physiology as most cases involve both parietal and visceral pericardium. We report the first case of asymptomatic epicarditis that involved only the visceral pericardium presenting without constrictive physiology.

Case presentation

A 71-year-old male with a history of atrial fibrillation, coronary artery disease, pericardial effusion, type-2 diabetes and hypothyroidism presented with 5 weeks of fatigue and 1 day of dizziness. Physical examination was significant for pallor and tachycardia. Laboratory analysis revealed a hemoglobin count of 7.2 g/dl and iron deficiency anemia. The patient was transfused and evaluated by endoscopic ultrasound. A polypoid mass in the gastric cardia was found and later diagnosed as gastric adenocarcinoma (staged as T1N0M0). The pericardial effusion was evaluated with transthoracic echocardiography which showed a 2.0 × 2.7 cm mass associated with the right atrium. Transesophageal echocardiography confirmed the mass but did not reveal constrictive physiology. Whole-body contrast computed tomography failed to demonstrate metastatic disease. Biopsy of the cardiac mass revealed epicarditis without parietal pericardium involvement. Partial gastrectomy was performed to remove the gastric adenocarcinoma.

Conclusion

This is the first reported case of asymptomatic epicarditis. Our case was especially unusual because the epicarditis presented as an incidental cardiac mass. The clinical picture was complicated due to the concomitant presence of gastric adenocarcinoma and chronic pericardial effusion. This case demonstrates that epicarditis should be considered in the differential diagnosis of cardiac masses.

Isolated subacute effusive and nonconstrictive epicarditis masquerading as a right atrial mass

Epicarditis (visceral pericardial inflammation) is a very unique and rare diagnosis. It is almost always associated with parietal pericardial involvement and may occur in medical conditions such as viral, bacterial (mycobacterial) infections and uremia or postoperatively in the setting of cardiac surgery. Frequently, no etiology is found. Most cases are associated with constrictive physiology, and patients present with symptoms and signs of right-sided heart failure. Effusive epicarditis is often present, and the clinical features may easily be confused with those of pericardial effusion with tamponade. We report a unique case of isolated subacute effusive and nonconstrictive epicarditis mimicking a right atrial mass in a 72-year-old patient who was diagnosed with nonmetastatic gastric adenocarcinoma. Our case is unique for several reasons: inflammation was limited to the epicardium (very few cases have been described to date); the patient was asymptomatic, with no clinical or echocardiographic evidence of constriction (this represents a novel finding, explained in part by the more limited extent of inflammation, with no significant fibrotic component and no parietal pericardial involvement); and this is the first report of epicarditis occurring in association with a malignancy, which we hypothesize may represent an inflammatory paraneoplastic process.

Cardiac Hemangioma Arising in the Epicardium

A 32-year-old housewife was treated for recurrent pericardial effusion with repeated pericardiocentesis and pleuropericardial window formation after a diagnosis of tuberculous pericarditis. The biopsied pericardium revealed nonspecific inflammation. In spite of continuing antituberculosis medication, she did not improve and the pericardial effusion increased with emerging signs of progressive right heart failure. A pericardiectomy was performed and multiple masses with a cobblestone appearance were found on the entire epicardium and the great vessels. The partially excised masses showed mesothelial hyperplasia and capillary hemangioma. The pericardial effusion continued and radiation therapy (2,000 cGy/2 weeks) was given with corticosteroid to control immune thrombocytopenic purpura. On the 87th postoperative day, a left posterolateral thoracotomy was performed to remove a large pleural hematoma which was compressing the left atrium and the left ventricle. We found extensive spread of the hemangioma into the pleural cavity along the intercostal vessels. The patient died 3 days later from massive uncontrollable hemorrhage.

Problems and pitfalls in the echocardiographic assessment of pericardial effusion

The echocardiographic diagnosis of pericardial effusions is usually based on visualization of a sonolucent circumcardiac space of varying width. However, potential fallacies in interpretation can arise if sonolucent spaces adjacent to the heart (pleural effusions, ascites, pericardial cysts) are mistaken for pericardial effusions. Loculated pericardial effusions, especially if unusual in location or configuration, can cause diagnostic difficulty on occasion. The differential diagnosis of various "solid" echoes within a pericardial effusion is of clinical relevance, yet not widely discussed. Inflammatory tissue, neoplastic involvement, pus, caseous material, and extravasated blood all have characteristic echocardiographic morphologies. All of the various reported echocardiographic signs of tamponade do not have the same significance, so that caution is necessary not to over- or under-read tamponade. Chamber collapse can be absent in real tamponade in specific situations. On the other hand, "regional" tamponade can occur if loculated pericardial effusions are sufficiently large and high tension; echocardiographic appearances are "atypical" but diagnostically valuable if correctly interpreted. These and certain other unusual variants of tamponade deserve to be better known among echocardiographers not only because of their intrinsic interest, but also to avoid potential pitfalls in the echocardiographic assessment of patients with suspected disease.