Cholesterol pericarditis. A specific but rare cause of pericardial disease

Abstract

During a diagnostic investigation in a 40-year-old male with pericardial effusion associated with hypothyroidism, cholesterol pericarditis was detected. We report a brief review on the etiopathogeny, clinical findings, and therapeutical possibilities of this entity.Pericardial diseases have diverse causes, which determine the different types of morphological involvement. A rare but specific entity is cholesterol pericarditis. This term is used in cases of chronic pericardial effusion with the presence of cholesterol crystals or an elevated concentration of cholesterol, or both 1 . Cases associated with systemic diseases, such as tuberculosis, rheumatoid arthritis, and hypothyroidism have been reported, as have idiopathic cases.The objective of this study was to report a case of cholesterol pericarditis and review the medical literature. Case ReportThe patient is a 40-year-old male from the city of Recife, in the Brazilian state of Pernambuco, who was referred to the Instituto do Coração with a diagnosis of pericardial effusion of unknown etiology. The patient reported that 6 months prior to hospital admission he began to feel progressively tired on exertion, and also noted edema in the lower limbs and enlargement of the abdominal volume. A chest Xray depicted an enlarged cardiac silhouette. An electrocardiogram showed low-voltage QRS complexes. An echocardiogram revealed a significant pericardial effusion with no signs of restriction. The laboratory test results were as follows: total cholesterol of 322mg/dL; triglycerides of 386mg/ dL; antinuclear factor, LE cells, and rheumatoid factor were negative. Measurements of thyroid hormones were as follows: T3 = 0.2 ng/mL (0.8-2.0); T4 = 1.2 µg/dL (4.5-12.5); and TSH >47 µIU/mL (0.3-4.5). The diagnostic hypothesis of pericardial effusion secondary to hypothyroidism was established and treatment with 50 µg of levothyroxine (Puran T4®) per day was started. As the patient remained clinically symptomatic in NYHA functional class IV, we decided to perform a pericardial drainage via video pericardioscopy on 9/5/98. An anterior pericardiotomy was performed, and 2000 mL of pericardial fluid of a gold-yellow color were withdrawn. Microscopic examination revealed the presence of multinucleated giant cells compatible with a chronic inflammatory process. The search for neoplastic cells, bacteria, and fungi was negative. Results of the biochemical analysis of the pericardial fluid were as follows: amylase, 65; cholesterol, 63 (normal up to 70mg/dL); glucose, 83mg/dL; triglycerides, 10mg/dL; total protein, 7.1; albumin, 5; and lactic dehydrogenase, 218 U/L. The anatomicopathological study revealed mild fibrosis, lymphocytic and plasmacytic infiltrate, and proliferation of capillary vessels. The material adhered to the pericardium consisted of a large amount of xanthomatous macrophages ( fig. 1) and foreign body giant cells engulfing cholesterol crystals ( fig. 2). Deposits of intracytoplasmic hemosiderin in the macrophages were also found. On the basis of these findings, the diagno...

Primary chylopericardium: A case report and literature review

“…Other conditions that may mimic a chylous pericardium include cholesterol pericarditis (88,89) and purulent pericarditis (90,91), which can be complicated by a pericardial effusion with a positive chylous test. The pericardial effusion in cholesterol pericarditis typically appears orange and full of cholesterol crystals.…”

A Rare Case of Effusive Constrictive Cholesterol Pericarditis: A Case Report and Review

“…Most cases have an unclear etiology but can be associated with rheumatoid arthritis, tuberculosis infection, and hypothyroidism [1]. The hallmark of the effusion is the distinctively high levels of cholesterol.…”

“…The hallmark of the effusion is the distinctively high levels of cholesterol. Effusions are large and can cause compression and adherence of the visceral pericardium to the heart [1]. The classic findings in effusive-constrictive pericarditis are persistently elevated right atrial pressures after intrapericardial pressures have been reduced to normal levels after removal of intrapericardial fluid [2].…”

I Diretriz Brasileira de Miocardites e Pericardites

“…A pericardiocentese guiada pelo ecocardiograma apresenta menor risco de complicações e maior sucesso. Além disso, a injeção salina permite a localização da agulha durante o procedimento 209 . Após a introdução do cateter é importante a aferição da pressão da cavidade pericárdica seguida da aspiração do seu líquido.…”