Effusive-constrictive cholesterol pericarditis: a case report

Abstract

Background: Cholesterol pericarditis (CP) remains a rare pericardial disease characterized by chronic pericardial effusions with high cholesterol concentrations with or without the formation of cholesterol crystals. Effusions are often large and can cause ventricular compression and subsequent pericardial adhesion formation. CP can be idiopathic but has associations with rheumatoid arthritis (RA), tuberculosis and hypothyroidism.

Case summary: We present a case of a 72-year-old male with a background of seropositive RA with a finding of an incidental pericardial effusion on computed tomography thorax abdomen and pelvis. Transthoracic echocardiogram demonstrated a large effusion with echocardiographic features of tamponade. On review, he was breathless with a raised venous pressure, bilateral ankle oedema, and pulsus paradoxus was present. Pericardial drainage was performed with fluid analysis demonstrating a cholesterol concentration of 8.3 mmol/L and numerous cholesterol crystal formation. Interval imaging demonstrated recurrence of the effusion with pericardial thickening and progressive constriction. He remained asymptomatic and underwent a successful pericardial window. At present, he is under close clinical outpatient surveillance with symptoms guiding a future pericardiectomy if warranted.

Discussion: CP can present as an emergent situation with signs and symptoms of acute heart failure with prompt pericardiocentesis required in cases of clinical tamponade. However, the disease course is often one of chronicity with relapsing large effusions that tend to recur following drainage, with the development of pericardial constriction necessitating pericardiectomy for definitive management.

Keywords: Case report; Cholesterol pericarditis; Effusive-constrictive pericarditis; Pericardial effusion; Pericardiectomy; Rheumatoid arthritis; Tamponade.

Figure 1

Contrast enhanced computed tomography thorax abdomen and pelvis in arterial phase with soft tissue windowing demonstrating the incidental encysted pericardial effusion (arrowed) in axial plane (A) and sagittal plane (B).

Figure 2

Transthoracic echocardiogram demonstrating the large pericardial effusion dimensions. (A) Parasternal long-axis with 11 mm posterior to the left ventricle. (B) Apical four-chamber with 33 mm anterior to right atrium. (C) Subcostal window with 36 mm anterior to right ventricle. (D) 38 mm apically in subcostal SAX.

Figure 3

Admission electrocardiogram demonstrating sinus rhythm, anterior Q-waves, right axis deviation, and low voltage complexes.

Figure 4

Interval unenhanced computed tomography thorax with soft tissue windowing in axial plane demonstrating the thickened parietal pericardium of 4.8 mm (arrowed green) and distorted cardiac border against the visceral pericardium (arrowed orange).