Constrictive pericarditis following Coxsackie virus infection

Abstract

Infection with Coxsackie B2 virus is described in a 49-year-old farmer in whom myopericarditis and pneumonitis was followed over a period of 10 months by constrictive pericarditis.The differentiation between restrictive cardiomyopathy and constrictive pericarditis was not achieved without exploratory thoracotomy. The adherent pericardium was successfully excised with complete relief.The literature is reviewed and it is suggested that the development of constriction following Coxsackie pericarditis must be considered at subsequent examinations of the patient. CASE REPORTThe patient, a farmer born in 1920, was well until October 1967, when he developed a feverish illness with an ache in the right chest and shoulder, a dry cough, generalized myalgia, and lassitude. The illness subsided after two days, with persistence of the dry cough for a few weeks. A week after the onset there was a mid-systolic click, widely heard over the precordium, followed at the apex by a short systolic murmur. A chest radiograph was normal and an electrocardiogram showed non-specific T wave flattening from inferior leads.He remained well until June 1968, when he developed epigastric discomfort, a feeling of fullness in the neck, an unproductive cough, pyrexia, profuse night sweats, and increasing dyspnoea on effort. There was an elevation of the jugular pressure to 10 cm., persistent sinus tachycardia, a blood pressure of 100/ 70 mm. Hg, low-grade pyrexia, pericardial friction, fine inspiratory pulmonary basal crepitations, ankle and sacral oedema, and tender liver enlargement. The ESR was 38 mm./hour, rising to 72 mm./hour during the next 10 days. The WBC was 11,600/cu. mm., neutrophils 78%, lymphocytes 18%, and monocytes 4%, and haemoglobin 119 g./100 ml. Blood cultures and tests for antinuclear factor were negative. The aspartate aminotransferase was 115 units/ml. and hydroxybutyrate dehydrogenase 333 units/ml. Both enzymes were normal 14 days later. Mantoux tests at dilutions of 1/1,000 and 1 /100 were negative and the antistreptolysin 0 titre was less than 100 Todd units/ ml. A serial electrocardiogram showed no change. The chest radiograph showed cardiac enlargement, pulmonary congestion, and consolidation in the right lower lobe.

Clinical features of non-tuberculous constrictive pericarditis

“…Gibson (1959) described a syndrome termed 'atypical constrictive pericarditis' in which very severe cardiac constriction was present despite the absence of third heart sounds. In other reports of non-tuberculous pericarditis, it was present in two cases of post- Coxsackie constrictive pericarditis (Howard and Maier, 1968;Matthews et al, 1970) but absent in four cases of non-specific constrictive pericarditis (Robertson and Arnold, 1965;Harrold, 1968). The lack of this sound in three of our cases indicates that it may be a particularly unreliable physical sign in constrictive pericarditis of non-tuberculous aetiology.…”

“…This finding is in contrast to tuberculous constriction. Large amplitude 'a' waves have also been recorded in non-tuberculous constriction by Matthews et al (1970) and Robertson and Arnold (1962). The exaggerated atrial wave in these cases probably reflects the atrium assisting in the filling of a non-compliant constricted ventricle.…”

“…The lesser degree of pericardial thickening and its patchy distribution minimize the help from special investigations. This has also been the experience of several others, and it is recommended that, if the diagnosis remains in doubt after radiological investigations, exploratory thoracotomy is obligatory (Robertson and Arnold, 1965;Matthews et al, 1970).…”

“…The difficulty in diagnosing this type of cardiac constriction has been noted by many authors (Robertson and Arnold, 1962;Howard and Maier, 1968;Matthews et al, 1970;McHenry, Ord, Johnston, and Schoener, 1965). The object of our report is to determine features that may be reliable in reaching a diagnosis.…”

“…Several papers have reported the progression of acute idiopathic and acute viral pericarditis to constrictive pericarditis, and this is now widely accepted (Krook, 1954;Rabiner, Specter, Ripstein, and Schlecker, 1954;Connolly and Burchell, 1961;Robertson andArnold, 1962, 1965;Gibbons, Goldbloom, and Dobell, 1965;Harrold, 1968;Howard and Maier, 1968;Matthews, Cameron and George, 1970).…”