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

A-47-Year-Old-Man-With-Recurrent-Unilateral-Pleura

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The document presents a case of a 47-year-old man with a medical history of hypertension, diabetes, hyperlipidemia, and obstructive sleep apnea who experienced worsening dyspnea on exertion and walking limitations. Upon examination, the patient exhibited decreased breath sounds over the lower part of the left lung and bilateral lower extremity swelling, yet had normal cardiac rhythm without murmurs. Diagnostic tests revealed an enlarged right ventricle, right ventricular hypertrophy, left ventricular hypertrophy, and a significant left pleural effusion. Thoracentesis showed an exudative effusion with no malignant cells, and further imaging pointed to potential cardiac involvement.<br /><br />A cardiac catheterization indicated constrictive pericarditis, characterized by diastolic ventricular pressure equalization and ventricular discordance. The pathology showed thickened pericardium with chronic fibrosis. The condition is described as an uncommon cause of recurrent unilateral pleural effusions but can raise suspicion when observed alongside symptoms of heart failure, history of cardiac surgery, or infections, and visible pericardial thickening and calcification through imaging.<br /><br />The pathophysiology involves loss of pericardial compliance leading to impaired ventricular diastolic filling, ultimately causing venous congestion and heart failure. Most pleural effusions resulting from this condition present as exudative due to underlying inflammation.<br /><br />For diagnosis, echocardiography and cardiac MRI are beneficial, while cardiac catheterization remains the gold standard. Treatment involves pericardiectomy, which showed symptom relief in a majority of patients. The patient underwent pericardiectomy and experienced symptom resolution, suggesting viral pleuropericarditis as the underlying cause. This case underscores the need for clinical suspicion in similar presentations to avoid misdiagnosis and ensure appropriate treatment.

Keywords

constrictive pericarditis

pleural effusion

pericardiectomy

cardiac catheterization

ventricular hypertrophy

dyspnea

echocardiography

cardiac MRI

viral pleuropericarditis

pericardial thickening