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Rapid progression of pericardial malignant mesothelioma

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A 19 year old man with no history of cardiac disease had been admitted to another hospital six months previously with progressively worsening breathlessness and a decrease in exercise tolerance. Chest radiography showed cardiomegaly and echocardiography showed pericardial effusion, moderate ventricular function, no valve dysfunction, and a bad collapsing inferior vena cava. Although malignancy was suspected, this could not be confirmed by either echocardiography (abdomen) or computed tomography of the chest and abdomen. Pericardiocentesis released two litres of clean fluid that contained only inflammatory cells. Despite repeated echocardiography no recurrent pericardial effusion was seen.

After six months he returned with massive pericardial effusion. On examination in our hospital he was unwell, short of breath, had a regular pulse, and no pulses

paradoxes. There were signs of cardiomegaly, normal heart sounds and systolic murmur. Echocardiography showed massive pericardial effusion and a solid structure at the apex and the left posterior ventricular wall. Both ventricles were compressed. Magnetic resonance imaging showed massive myocardial infiltration with a large mass infiltrating into the posterior left ventricular wall (10 × 7 × 7 cm). There was also infiltration of the mediastinum and around the arcus aorta. Besides mild pleural effusion, no other (thoracic or abdomen) tumour sites were found.

 A small lateral thoracotomy was performed and tissue was obtained. Histological examination revealed a primary malignant pericardial tumour, probably mesothelioma. Within six months of the first evidence for pericardial effusion the patient died from inflow restriction. (IS, interventricular septum; IM, infiltrating mass; LV, left ventricle; PE, pericardial effusion; RV, right ventricle; T, tumour.)