Transient Effusive Constrictive Pericarditis Caused by E.Coli and E.Faecium in a Patient with a History of Esophageal Adenocarcinoma Treated with Surgery, Chemotherapy and Radiation

Jul 08, 2020   |  Rohini Manaktala, DO, FACC; Salima Qamruddin, MD, FACC; ; Yvonne E. Gilliland, MD, FACC; Sangeeta B. Shah, MD, FACC; Allan L. Klein, MD, CM, FACC
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A 59-year-old male presented to the Emergency Department with two weeks duration of non-productive cough, shortness of breath and chest pressure. Past medical history included: esophageal adenocarcinoma, partial esophagectomy, chemotherapy (Carbo-Taxol) and radiation treatments along with repeated esophageal dilations due to recurrent esophageal strictures. Initial workup involved a transthoracic echocardiogram that identified a large circumferential pericardial effusion (Figure 1), respirophasic septal shift and significant mitral and tricuspid valve respiratory inflow variations (Figure 2).

Figure 1

Figure 1
Figure 1. A4 chamber view showing pericardial effusion.
[Pericardial Effusion (PE), Right Ventricle (RV), Right Atrium (RA), Left Ventricle (LV), Left Atrium (LA)].

Figure 2

Figure 2
Figure 2. Respiratory inflow variation across Tricuspid valve. [I = inspiration, E = expiration].

Annulus reversus was also seen. The mitral e' septal annulus tissue Doppler velocity was greater than mitral e' lateral annulus tissue Doppler velocity (Figures 3 and 4). The patient was hospitalized for further workup and management.

Figure 3

Figure 3

Figure 4

Figure 4
Figures 3 and 4. Demonstration of annulus reversus. Mitral e' septal annulus velocity 0.09 m/s. Mitral e' lateral annulus velocity 0.06 m/s.

Pericardiocentesis drained sanguineous, purulent fluid that grew E.Coli and E.Faecium. Antibiotic therapy was initiated to treat bacterial pericarditis. A few days later, a cardiac catheterization was performed and showed ventricular interdependence and equalization of right and left sided diastolic pressures (Figure 5). Subsequent cardiac magnetic resonance imaging (MRI) revealed pericardial thickening and diffuse pericardial late gadolinium enhancement. It also showed prolonged myocardial relaxation time and increased signal on T2-weighted images suggestive of pericardial inflammation (Figure 6). The patient was diagnosed with effusive constrictive pericarditis.

Figure 5

Figure 5
Figure 5. Cardiac catheterization pressure tracings showing simultaneous recording of left and right ventricular pressure with similar ventricular end diastolic pressures. This is specific to constrictive pericarditis as it results from equal exerted pressure on all cardiac chambers by the fixed pericardium. Also seen is discordant respiratory variation of the left and right ventricular pressures. During inspiration, there is a rise in right ventricle filling pressure in order to maintain forward flow while there is a fall in left ventricle filling pressure. The right ventricle fills at the expense of left ventricle in the setting of a fixed pericardium. And vice versa occurs during expiration. This phenomenon, known as ventricular interdependence, is a hallmark finding in constrictive pericarditis.

Figure 6

Figure 6
Figure 6. Cardiovascular magnetic resonance (CMR) FS-T2 demonstrating pericardial inflammation.

Antibiotics, colchicine, indomethacin and medical therapy for symptoms of heart failure were started. Prednisone was initiated due to marked pericardial inflammation on the cardiac MRI. A repeat transthoracic echocardiogram performed after six months on medical therapy showed resolution of the mitral and tricuspid valve inflow respiratory variations. A mild residual septal bounce was still present. Repeat cardiac MRI showed reduced pericardial inflammation (Figure 7).

Figure 7

Figure 7
Figure 7. Follow-up CMR showing reduced pericardial inflammation.

The translocation of intestinal flora into the pericardial space was thought to be secondary to the repeated esophageal dilatations although no esophago-pericardial fistula was identified at that time by esophagogram, endoscopy and chest computerized tomography (CT).

Which of the following statements is correct regarding the sensitivity of the imaging modality finding used in diagnosing constrictive pericarditis (CP)?

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