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Case Reports
. 2021 Sep 24;4(2):237-239.
doi: 10.1016/j.cjco.2021.09.018. eCollection 2022 Feb.

Aggressive Cholesterol Pericarditis With Minimal Effusion Masquerading as Treatment-Refractory Autoimmune Disease

Tahir S Kafil  1 , Elena Tugaleva  2 , Muhammad M Hashmi  3 , Omar Shaikh  4 , Yehia Fanous  5 , Tahir Dahrouj  6 , Maged Elrayes  1 , Lin-Rui Ray Guo  7 , Rodrigo Bagur  1 , Nikolaos Tzemos  1
Affiliations
Case Reports

Aggressive Cholesterol Pericarditis With Minimal Effusion Masquerading as Treatment-Refractory Autoimmune Disease

Tahir S Kafil et al. CJC Open. .

Abstract
in English, French

A middle-aged woman with rheumatoid arthritis presented with treatment-refractory pericarditis. Symptoms persisted despite escalation of immunosuppression, and she had recurrent admissions for heart failure. Imaging revealed minimal pericardial effusion and a thickened pericardium. Invasive hemodynamics confirmed constrictive physiology, and a pericardiectomy was required. Pathology testing confirmed cholesterol pericarditis, a rare condition of inflammatory cholesterol deposits within the pericardium. Previous reports describe moderate-to-large volumes of gold-coloured pericardial fluid. This case illustrates that cholesterol pericarditis can present with minimal pericardial effusion and rapidly progress to pericardial constriction.

Une femme d’âge moyen atteinte d’arthrite rhumatoïde a présenté une péricardite réfractaire. Les symptômes ont persisté en dépit de l’escalade de l’immunodépression. Elle a été admise de façon répétitive en raison d’insuffisance cardiaque. L’imagerie a révélé un épanchement péricardique minimal et un péricarde épaissi. L’exploration hémodynamique invasive a permis de confirmer la physiologie constrictive. Une péricardectomie a été nécessaire. L’examen pathologique a permis de confirmer la péricardite cholestérolique, une affection inflammatoire rare due aux dépôts de cholestérol dans le péricarde. Les observations précédentes décrivent des volumes modérés à élevés de liquide péricardique doré. Ce cas illustre que la péricardite cholestérolique peut se traduire par un épanchement péricardique minimal et progresser rapidement vers la péricardite constrictive.

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Figures

Figure 1
Figure 1
(A) Echocardiography showed minimal pericardial effusion, <10 mm (blue arrow) and a thickened pericardium (red arrow). (B) Computed tomography of the heart showed a thickened pericardium measuring up to 3 mm (red arrow), but no calcification. (C) Hemodynamics tracing showed equalization of left ventricular end-diastolic pressure and right ventricular end-diastolic pressure (red arrow), square-root sign (blue arrow), ventricular interdependence (green arrow indicating inspiration), and high right ventricular end-diastolic pressure.
Figure 2
Figure 2
(A) Intraoperatively, a very thick pericardium (white arrow) was discovered around the myocardium (blue arrow). (B) Histopathology testing showed dense fibrosis in the pericardium, focal chronic inflammation, and variably sized collections of cholesterol material (blue arrow). (C) Histopathology testing showed cholesterol clefts within the pericardial tissue. The empty spindle-shaped spaces are cholesterol crystals (blue arrow).
See this image and copyright information in PMC

References

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