Delayed diagnosis of postcardiac injury syndrome

Abstract

Postcardiac injury syndrome (PCIS) is a rare condition that is considered to have a trauma-induced autoimmune mechanism triggered by damage to pericardial and/or pleural tissues. We report a case of PCIS accompanied by systemic oedema after thymectomy. A 73-year-old woman was referred to our hospital for dyspnoea and oedema, 9 months after thymectomy. Evaluation revealed the presence of pericardial effusion, pleural effusion and systemic oedema. Differential diagnosis included constrictive pericarditis (secondary to tuberculosis), serositis caused by collagen disease and malignancy. Detailed investigations led to the diagnosis of PCIS, which was successfully treated with prednisolone. This report focuses on the diagnostic approach to PCIS. Since it took time to make a final diagnosis in our patient, we analysed several past case reports and series to determine the cause of the delay in diagnosis.

Keywords: heart failure; immunology; pericardial disease.

Figure 1

(A) Chest X-ray performed 9 months after thymectomy showed cardiomegaly and pleural effusion bilaterally. (B) Chest X-ray performed 2 months after thymectomy showed no cardiomegaly and pleural effusion.

Figure 2

Chest CT imaging after admission showed bilateral pleural effusion, pericardial effusion and no recurrence of thymoma.

Figure 3

Nuclear scintigraphy imaging (99mTc-human serum albumin) showed no evidence of protein-losing gastroenteropathy.

Figure 4

(A) Biopsy specimen of pleura showed non-specific inflammatory change (fibrous hyperplasia and sporadic inflammatory invasion). (B) Biopsy specimen of pericardium showed non-specific inflammatory change.