Case Report
A 41-year-old man with no medical history was referred to our hospital due to progressive dyspnea associated with edema of the lower limbs, pleural effusion, and significant weight loss (30 Kg) for 5 months. Physical examination revealed hypophonetic heart sounds, jugular stasis at 45º and hepatojugular reflux, decreased breath sound bilaterally with signs of respiratory effort, and moderate pitting edema on both pretibial areas.
TTE showed pericardial thickening with adhesion, dilated inferior vena cava (28 mm in diameter and respiratory variation less than 50%), preserved left ventricular ejection fraction (LVEF), and preserved RV function, end-diastolic volume, and end-systolic volume (Figure 1A and 1B). Chest CT showed moderate bilateral pleural effusion determining restrictive atelectasis of the adjacent pulmonary parenchyma. The patient underwent thoracentesis, the findings of which were nonspecific and did not allow the identification of the etiology of the pleural effusion.
Considering the probable diagnosis of constrictive pericarditis and the presence of symptoms, pericardiectomy by median sternotomy with cardiopulmonary bypass and bilateral pleural drainage were performed, with removal of approximately 1500 mL on the left and 200 mL on the right. The procedure included the complete removal of the anterior pericardium between the two phrenic nerves and the removal of the diaphragmatic pericardium and of part the pericardium posterior. The anatomopathological exam revealed chronic granulomatous pleuritis and chronic granulomatous pericarditis with extensive areas of caseous necrosis, and anti-tuberculosis therapy was initiated (rifampicin 150 mg, isoniazid 75 mg, pyrazinamide 400 mg, and ethambutol 275 mg 5 tablets daily for 2 months, followed by 4 months of rifampicin 150 mg and isoniazid 75 mg 5 tablets daily). Three postoperative TTEs demonstrated preserved biventricular function and mild pericardial thickening. The patient was discharged from the hospital 8 days after the pericardiectomy.
Two weeks after surgery, he was admitted to the emergency department with dyspnea and hypoxemia. Physical examination again revealed jugular stasis at 45º and hepatojugular reflux, decreased breath sound bilaterally, and moderate pitting edema on both pretibial areas. He presented with a heart rate of 93 beats per minute, blood pressure of 119/85 mm Hg, and body temperature of 36.3°C. Respiratory rate was 31 breaths per minute with 89% peripheral oxygen saturation without supplementary oxygen. The electrocardiogram (ECG) on admission showed sinus rhythm with nonspecific ST-T repolarization abnormalities (Figure 2)
A new TTE showed preserved LVEF, severe RV dysfunction, mild tricuspid and mitral regurgitation, and mild pericardial thickening (Figure 1C and 1D). Chest CT revealed recurrence of moderate pleural effusion, this time loculated, with restrictive atelectasis of the adjacent lung parenchyma (Figure 3). He developed respiratory failure, and hemodynamic instability, requiring intubation. Dobutamine 7.5 mcg/kg/min and diuretics were started. Corticosteroids and antibiotics were prescribed and the loculated pleural effusion was drained. Dobutamine was weaned off by day 15 of admission. TTE performed on day 24 revealed a decreased RV chamber size with improved RV systolic function (Figure 1E and 1F). He was discharged stable 30 days after admission with low dose oral furosemide. Four months after discharge, he remained asymptomatic with good functional status and normal exercise capacity.