We describe a patient who suffered progressive right heart failure of unknown aetiology, despite a lengthy series of hospital investigations. Constrictive pericarditis had not been suspected during life, and was ultimately diagnosed as an autopsy finding. The salient clinical features and confirmatory investigations for this unusual disorder are reviewed. The case reminds us to consider the possibility of constrictive pericarditis in patients with unexplained chronic right heart failure, so that prompt investigation and treatment can be instigated.
Case ReportA 76-year-old woman attended a gastroenterology outpatient clinic for investigation of unexplained weight loss and diffuse abdominal distension. Investigations showed deranged liver biochemistry tests, and computed tomography showed widespread ascites and a small pleural effusion but no focal organ pathology. Analysis of ascitic fluid showed total protein 34 g/L, and 3 white cells per mm 3 . The patient was subsequently referred to a cardiologist, who noted the presence of a soft systolic murmur. An echocardiogram showed normal left ventricular dimensions and function, but the right heart chambers were dilated and there was moderate to severe tricuspid regurgitation. Cor pulmonale was suspected and, therefore, the patient was referred to a respiratory clinic for investigation of possible underlying lung disease. The patient had been a non-smoker, with no past history of occupational exposure or tuberculosis. Spirometry was normal and computed tomography pulmonary angiography showed patent pulmonary arteries, and small bilateral pleural effusions. Cardiac catheterisation studies were proposed, but patient defaulted from clinic.Eighteen months later, the patient was admitted to hospital in extremis. Initial examination found temperature 34.6°C, blood pressure 65/30 mmHg, and heart rate 85 min -1 . The patient had reduced conscious level, cool peripheries, and elevated jugular venous pressure. An electrocardiogram showed atrial fibrillation and right bundle branch block. She was diagnosed with sepsis and dehydration, and treated with intravenous colloid administration, gradual warming, and systemic antibiotics. Despite these measures, hypotension and tissue perfusion progressively worsened and the patient died shortly after arrival in hospital.Autopsy examination found extensive constrictive pericarditis and chronic hepatic congestion. Additional findings were colonic diverticular disease and gastrointestinal ischaemia. Death was attributed to heart failure secondary to constrictive pericarditis, exacerbated by sepsis and tissue ischaemia. The earlier investigative findings, which were performed over a 12-month duration, were attributable, in retrospect, to constrictive pericarditis. There had been no specific clinical signs suggestive of this diagnosis.
