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A 64 year old man was diagnosed with non-Hodgkin's lymphoma (B cell, follicular and small cell) based on the axillary lymph node biopsy. He consulted our department because of general fatigue, dyspnoea, and peripheral oedema. Chest x ray and computed tomographic images revealed bilateral pleural effusion and no calcified lesions, including the pericardium. Pleural fluid cytology revealed lymphocytes (CD 3+, 5+, 7+, HLA-DR+). Chest magnetic resonance imaging (MRI) (Toshiba, Tokyo, Japan) of T1 weighted image after gadolinium injection showed a thickened pericardium and a mild pericardial effusion (below left). Right heart cardiac catheterisation revealed increases in right ventricular end diastolic pressure (RVEDP) of 16 mm Hg and mean right atrial pressure (mRAP) of 13 mm Hg. Right ventricular pressure waveform showed an undershoot in early diastole and an overshoot during atrial contraction.
A pericardiectomy was performed. Histopathology (haematoxylin and eosin staining) of the pericardium revealed layered diffuse infiltration of lymphoma cells and pericardial fibrosis (below centre and right). Cardiac catheterisation after the operation revealed decreases in RVEDP of 11 mm Hg and mRAP of 11 mm Hg. The right ventricular pressure pattern was normalised.
In the present case, diagnosed as chronic effusive constrictive pericarditis, diffuse peri cardial thickening and infiltration with lymphoma cells were observed. Rarely, such involvement produces rubber-like changes in the pericardium, which may impair the ventricular filling but may not be identical to a typical constrictive pericarditis with a rigid pericardium. MRI with gadolinium injection and fat suppression technique improves the quality of the pericardial image, and was crucial for diagnosing rubber-like changes of the pericardium.