CHEST Guidelines-A-47-Year-Old-Man-With-Recurrent-Unilateral-Pleura (1)

A-47-Year-Old-Man-With-Recurrent-Unilateral-Pleura (1)

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A 47-year-old man with a history of hypertension, diabetes, hyperlipidemia, and obstructive sleep apnea presented with worsening shortness of breath and was found to have a large left pleural effusion. Despite multiple thoracenteses, the effusion recurred rapidly. Diagnostic imaging showed an enlarged right ventricle and left ventricular hypertrophy, leading to cardiac catheterization, which revealed signs consistent with constrictive pericarditis—a condition characterized by a non-compliant pericardium restricting heart function. <br /><br />Thoracoscopic pleural biopsy showed chronic pleuritis with fibrosis and calcification, suggesting an inflammatory process. Although constrictive pericarditis often presents with pleural effusions, they are typically exudative due to underlying inflammation rather than transudative, which would be expected if the effusion were a result of heart failure alone. <br /><br />The pathophysiology of constrictive pericarditis involves a loss of pericardial compliance, limiting the heart's ability to fill during diastole, leading to increased venous pressure and heart failure-like symptoms. Advanced imaging, such as echocardiography and cardiac MRI, along with cardiac catheterization, provide crucial diagnostic information by showing characteristic signs of constriction and ventricular interdependence.<br /><br />Constrictive pericarditis treatment involves pericardiectomy, which can provide significant symptom relief and improve survival. In this case, the patient underwent pericardiectomy with resolution of his symptoms, supporting the diagnosis.<br /><br />The case underscores the importance of considering constrictive pericarditis in the differential diagnosis of recurrent pleural effusions, particularly in patients with risk factors. It also highlights the need for high clinical suspicion as the symptoms often mimic those of congestive heart failure, and requires comprehensive evaluation including advanced imaging and potentially surgical intervention for resolution.

Keywords

constrictive pericarditis

pleural effusion

cardiac catheterization

pericardiectomy

chronic pleuritis

ventricular hypertrophy

cardiac MRI

echocardiography

heart failure symptoms

thoracoscopic biopsy