Dataset Information

Constrictive pericarditis as a rare cause of chylothorax: a case report.

ABSTRACT:

Background

Chylothorax is a rare clinical condition that results from thoracic duct damage with leakage of chyle from the lymphatic system to the pleural space. Rarely, constrictive pericarditis has been associated with chylothorax, but to our knowledge only in relation to secondary causes such as tuberculosis, HIV, or malignancy.

Case summary

A previously healthy 63-year-old man presented with effusive-constrictive pericarditis, recurrent right-sided pleural effusion, and chylothorax. There was no history of co-morbidities, surgical illness, or cardiac procedures. No single aetiologic factor was identified despite comprehensive assessment. Substantial immunosuppressive therapy was given without a sufficient clinical response. Pericardiectomy resulted in resolution of the constrictive haemodynamics and terminated chylous effusion.

Discussion

The hypothesized mechanisms for development of chylothorax in association with constrictive pericarditis are the increased effective capillary infiltration secondary to central venous hypertension and reduced lymphatic drainage due to high pressure in the left subclavian vein. Increased capillary filtration may result in excessive lymph formation. However, the mechanism is not completely understood.

SUBMITTER: Lyng CS

PROVIDER: S-EPMC6426027 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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Publications

Constrictive pericarditis as a rare cause of chylothorax: a case report.

Lyng Camilla Simonsen CS Vegsundvåg Johnny J Wahba Alexander A Grenne Bjørnar B

European heart journal. Case reports 20181022 4

<h4>Background</h4>Chylothorax is a rare clinical condition that results from thoracic duct damage with leakage of chyle from the lymphatic system to the pleural space. Rarely, constrictive pericarditis has been associated with chylothorax, but to our knowledge only in relation to secondary causes such as tuberculosis, HIV, or malignancy.<h4>Case summary</h4>A previously healthy 63-year-old man presented with effusive-constrictive pericarditis, recurrent right-sided pleural effusion, and chyloth ...[more]

PMID: 31020189

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Project description:BackgroundTransient constrictive pericarditis (TCP) is a distinct constrictive pericarditis (CP) subtype characterized by acute pericardial inflammation and transient constrictive physiology. If left untreated, it may progress to irreversible CP requiring pericardiectomy. However, making an early diagnosis of TCP remains difficult.Case presentationA 51-year-old man presented with fever, chest pain, and dyspnea following preceding flu symptoms. An initial investigation suggested right-sided heart failure. Laboratory results revealed elevated inflammatory markers and hepatic enzyme levels. Echocardiography revealed pericardial effusion with a normal ejection fraction and diastolic ventricular septal bounce suggestive of pericardial constriction. Computed tomography suggested acute descending mediastinitis with pericarditis and pleuritis; however, detailed examinations ruled out this possibility. The constellation of increased serological inflammation, pericardial thickness/effusion, and constrictive physiology suggested TCP, confirmed by cardiac magnetic resonance (CMR) and hemodynamic studies. CMR also revealed coexistent myocarditis. After a thorough assessment for the cause of TCP, a viral etiology was suspected. Paired serology for virus antibody titers revealed a significant increase only in coxsackievirus A4 (CVA4) titers. With prompt anti-inflammatory treatment, the patient's pericardial structure and function and concomitant inflammation of the surrounding tissues were nearly completely recovered, leading to a final diagnosis of TCP caused by CVA4. The subsequent clinical course was uneventful without recurrence at the 1-year follow-up.ConclusionsHere we described the first case of TCP caused by CVA4 concurrent with mediastinitis, myocarditis, and pleuritis, all of which were successfully resolved with anti-inflammatory treatment. Acute mediastinitis secondary to TCP is rare. This case highlights the clinical importance of assessing pericardial diseases as a source of acute mediastinitis and considering CVA4 as an etiology of TCP. An evaluation including multimodal cardiac imaging and serology for virus antibody titers may be useful for an exploratory diagnosis of TCP in right-sided heart failure patients with pericardial effusion.

Project description:INTRODUCTION: Constrictive pericarditis is a heterogeneous disease with many causes. Traumatic hemopericardium is an uncommon initiating cause. We report the case of a man developing constrictive pericarditis after blunt chest trauma, in order to highlight an approach to diagnosing the condition and to raise awareness of the possibility of this condition developing after blunt trauma. CASE PRESENTATION: A 72-year-old Caucasian man presented initially to our outpatient clinic with a one-year history of progressively worsening dyspnea, and recent onset of edema of the legs. He was later taken to the emergency department and admitted to hospital. He had previously received unsuccessful treatment from his local primary physicians for suspected respiratory disorder and cellulitis of his legs. Echocardiography showed evidence of pericardial constriction, and computed tomography revealed nodular, lobulated thickening of the pericardium and pleura bilaterally. Interventional biopsies were taken, but gave inconclusive results. Thus, as pericarditis and/or advanced malignancy were suspected, diagnostic video-assisted thoracoscopic surgery was performed to take biopsies from the abnormal lung and pericardial tissue. Examination of these supported the diagnosis of pericarditis, as acute and chronic inflammation and fibrous thickening were found, with no evidence of malignancy. Our patient underwent cardiac catheterization, which revealed three-vessel coronary artery disease. Emergency total pericardiectomy and coronary bypass were performed. Having excluded other common initiating factors, we considered that a blunt trauma that our patient had previously sustained to his chest was the potential cause of the constrictive pericarditis. CONCLUSION: This was an interesting case of blunt chest trauma followed by progressive pericardial and pleural thickening. Subsequent development of chronic constrictive pericarditis occurred, requiring treatment by surgical pericardiectomy, as the clinical course of constrictive pericarditis is usually progressive without surgical intervention. Diagnosis of constrictive pericarditis remains challenging. Although uncommon, blunt trauma should be considered as a possible initiating cause. Delayed presentation of constrictive pericarditis should also be considered as a possible morbidity in a patient who has sustained blunt chest trauma. Our case also highlights the importance of performing echocardiography promptly in patients experiencing ongoing symptoms of congestive heart failure to allow earlier diagnosis of constrictive pericarditis or other cardiac disorders, and avoid unnecessary treatments.

Dataset Information

Constrictive pericarditis as a rare cause of chylothorax: a case report.

Background

Case summary

Discussion

Publications

Constrictive pericarditis as a rare cause of chylothorax: a case report.

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