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.