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• Re:Correspondence: A not so typical pericardial effusion case
  Rick A. Nishimura
  Published on: 15 March 2016
• Correspondence: A not so typical pericardial effusion case....
  George A. Lazaros
  Published on: 15 March 2016

• Published on: 15 March 2016

  Re:Correspondence: A not so typical pericardial effusion case

  • Rick A. Nishimura, Professor of Medicine
  • Other Contributors:
    • William R. Miranda, Darrell B. Newman

  To the Editor:

  We have read over and agree with the insightful comments of Lazaros at al. Our clinical vignette mainly focused on the hemodynamic abnormalities and post-pericardiocentesis diagnosis. Therefore, some of the clinical details had to be omitted for purposes of brevity. A pericardial rub was present during our patient's initial evaluation, and she later developed chest pain consistent with pericardi...

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  To the Editor:

  We have read over and agree with the insightful comments of Lazaros at al. Our clinical vignette mainly focused on the hemodynamic abnormalities and post-pericardiocentesis diagnosis. Therefore, some of the clinical details had to be omitted for purposes of brevity. A pericardial rub was present during our patient's initial evaluation, and she later developed chest pain consistent with pericardial irritation, confirming the diagnosis of "pericarditis". However, we do agree with the authors that the diagnosis is one that requires at least 2 out of 4 main criteria. With respect to treatment, nonsteroidal anti-inflammatory agents were not prescribed by the outside institution due a reported bleeding diathesis (which was later ruled out after hematologic evaluation at our institution), but we totally agree that colchicine should not be prescribed as monotherapy for acute pericarditis. The C-reactive protein was normal post-pericardiocentesis which, in the past, was thought to rule out an active inflammatory process. However, we have seen a number of patients with signs of pericardial inflammation on MRI scanning, despite normal serum inflammatory makers who have either responded to anti- inflammatory treatment or have been found to have an inflamed pericardium at the time of surgery. This indicates to us that MRI imaging may be more sensitive than serum markers in diagnosing pericardial inflammation. Finally, we agree that this was a case of "transient constriction" [1] which was unmasked after removal of a hemodynamically significant pericardial effusion. We do thank Lazaros et al for their comments.

  References:

  1 Feng D, Glockner J, Kim K, et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation 2011;124:1830 -7.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 15 March 2016

  Correspondence: A not so typical pericardial effusion case....

  • George A. Lazaros, Locum Consultant Cardiologist
  • Other Contributors:
    • Charalambos Vlachopoulos and Dimitrios Tousoulis

  To the Editor: We have read with interest the article of Miranda WR and coauthors1, in which a case of effusive-constrictive pericarditis is presented. This is a comprehensive and educational case that provides clinicians with a valuable message. Some points, however, require additional clarification in order to further strengthen the impact of this case. In particular, it is mentioned in the introduction that the patien...

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  To the Editor: We have read with interest the article of Miranda WR and coauthors1, in which a case of effusive-constrictive pericarditis is presented. This is a comprehensive and educational case that provides clinicians with a valuable message. Some points, however, require additional clarification in order to further strengthen the impact of this case. In particular, it is mentioned in the introduction that the patient was diagnosed with 'idiopathic pericarditis'. Nonetheless, the diagnosis of pericarditis is established in the presence of at least 2 out of the 4 main criteria including chest pain, pericardial friction, typical ECG changes and pericardial effusion.2 CRP elevation and pericardial inflammation in the cardiac magnetic resonance imaging (cMR) both constitute supportive findings. Accordingly, since only one diagnostic criterion was fulfilled (i.e. pericardial effusion), it should probably be more appropriate to 'label' the patient's disorder as 'idiopathic pericardial effusion' rather than 'idiopathic pericarditis'. Concerning treatment, the patient received initially colchicine as an outpatient, despite normal baseline CRP values. However, in the absence increased CRP levels, the efficacy of colchicine is questionable in chronic idiopathic pericardial effusion.3 Furthermore, even in the setting of idiopathic pericarditis, which this patient was presumed to have, colchicine is beneficial when administered in conjunction with either aspirin/non-steroidal anti-inflammatory (NSAID) medications or corticosteroids, but not as monotherapy.3 Another intriguing finding in this case was the demonstration of active pericardial inflammation in cMR. This is a quite unexpected finding in the presence of normal baseline CRP levels. Since pericardiocentesis and drainage catheters are potential triggers of pericardial inflammation, one wonders if pericardiocentesis was the actual cause of pericardial inflammation. Along this line, it would be interesting to know the post- pericardiocentesis serum CRP levels. Last but not least, the patient became asymptomatic and the jugular pressure normalized within 72 hours after aggressive NSAID therapy. This turn of events strongly suggests transient pericardial constriction, namely a reversible cause of pericardial constriction, which is occasionally observed towards the end of the effusive period of pericarditis.4 In conclusion, a final diagnosis of idiopathic pericardial effusion (possibly post-pericarditis) with transitory constriction probably unifies all aspects of this challenging case.

  References 1 Miranda WR, Newman DB, Nishimura RA. A not so typical pericardial effusion case....Heart 2015 Jun 17. pii: heartjnl-2015-308115. 2 Imazio M, Gaita F. Diagnosis and treatment of pericarditis. Heart 2015 Apr 8. pii: heartjnl-2014-306362. 3 Brucato A, Brambilla A, Adler Y, Spodick,D. Colchicine for Recurrent Acute Pericarditis. Arch Intern Med 2006;166:696. 4 Haley JH, Tajik AJ, Danielson GK, et al. Transient constrictive pericarditis: causes and natural history. J Am Coll Cardiol 2004;43:271-5.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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