Pseudomonas aeruginosa-related effusive-constrictive pericarditis diagnosed with echocardiography: A case report

Abstract

Background: Effusive-constrictive pericarditis (ECP) is an uncommon pericardial syndrome. Careful echocardiographic examination may provide helpful information not only for diagnosing but also for managing ECP. ECP has various etiologies; however, Pseudomonas aeruginosa (P. aeruginosa) infection has not been reported as a cause to date. Herein, we present a rare case of ECP caused by P. aeruginosa infection, which was followed up using echocardiography.

Case summary: A 30-year-old man was admitted to our hospital with a 2-mo history of cough, dyspnea, bloating, palpitations, and lower-extremity edema. The patient was initially diagnosed with pericardial effusion by transthoracic echocardiography. Drainage of pericardial effusion was performed to relieve the clinical symptoms. A follow-up echocardiogram showed that the pericardial effusion had decreased; however, the right atrial pressure continued to increase, and signs of constrictive pericarditis were observed upon a more comprehensive inspection. Therefore, the diagnosis of ECP was established based on the comprehensive pre- and post-pericardiocentesis echocardiographic findings. An urgent pericardectomy was subsequently performed, which significantly relieved the patient's clinical symptoms, and the signs of pericardial constriction on echocardiography improved. Pericardial effusion and pericardial culture showed growth of P. aeruginosa.

Conclusion: ECP induced by P. aeruginosa infection remains a rare disease. The presence of echocardiographic features of constrictive pericarditis after pericardiocentesis therapy is highly indicative of ECP.

Keywords: Case report; Echocardiography; Effusive-constrictive pericarditis; Pseudomonas aeruginosa infection.

Figure 1

Echocardiographic examinations before pericardiocentesis. A: The left atrium was significantly enlarged, with an anteroposterior diameter of 6.2 cm; B: The diameters of the left and right atrium were 5.9 cm × 6.1 cm and 5.0 cm × 6.0 cm, respectively. A moderate pericardial effusion that was predominantly along the apical wall, measuring up to 2.0 cm. LA: Left atrium; RA: Right atrium.

Figure 2

Echocardiographic examinations after pericardiocentesis. A: Right atrial (50 mm × 62 mm) and left atrial (61 mm × 61 mm) enlargement, increased pericardial thickness, and pericardial effusion that was located predominantly along the apical wall (measuring up to 1.2 cm); B and C: Dilated inferior vena cava (up to 2.5 cm) almost without any aspiratory variation (20%), indicating an elevated right atrial pressure of approximately 20 mmHg; D: Pulsed wave doppler of the mitral valve showed that the peak mitral E and A inflow velocity were 90 cm/s and 38 cm/s, respectively. The E/A ratio was > 2, indicating restricted mitral inflow velocity. Respiratory variation in the peak mitral E inflow velocity was 28% (peak E velocity during expiration and inspiration were 90 cm/s and 65 cm/s, respectively); E and F: Tissue Doppler imaging showed “annulus reversus” with the lateral mitral e’ velocity (12.9 cm/s) abnormally lower than the medial mitral e’ velocity (14.9 cm/s). IVC: Inferior vena cava; LA: Left atrium; RA: Right atrium.

Figure 3

The follow-up echocardiography 1 wk after pericardectomy. A: The diameters of the left and right atriam were 5.4 cm × 6.1 cm and 4.4 cm × 5.5 cm, respectively. The localized pericardial effusion disappeared; B and C: The diameter of the inferior vena cava (2.2 cm) and aspiratory variation were still lower than 50% (41%). The calculated right atrial pressure was lower than that before pericardectomy (12 mmHg); D: Pulsed-wave Doppler of the mitral valve showed that the peak mitral E and A inflow velocities were 92 cm/s and 49 cm/s, respectively. Respiratory variation in the peak mitral inflow velocity (E) was 15% (peak E velocity during expiration and inspiration were 92 cm/s and 78 cm/s, respectively); E and F: Tissue Doppler imaging revealed that the medial mitral e’ velocity (10.9 cm/s) was lower than the lateral mitral e’ velocity (16.8 cm/s). IVC: Inferior vena cava; LA: Left atrium; RA: Right atrium.

Figure 4

Histologic examination performed on the pericardial tissue revealed increased thickening with the proliferation of collagen fibers, hyaline degeneration, and calcification.

Figure 5

The follow-up echocardiography 1 mo after discharge. A: The size of the left atrium was smaller than before (5.3 cm × 5.5 cm), and the right atrium was approximately normal (3.4 cm × 4.2 cm) in the absence of pericardial effusion; B and C: The diameter of the inferior vena cava (1.9 cm) and aspiratory variation (greater than 50%) were normalized, based on which the calculated right atrial pressure was within the normal range, approximately 5 mmHg; D: Pulsed-wave Doppler of the mitral valve showed that the peak mitral E and A inflow velocities were 45 cm/s and 53 cm/s, respectively. The E/A ratio was < 1; E and F: Tissue Doppler imaging showed that the medial mitral e’ velocity (8.2 cm/s) was lower than the lateral mitral e’ velocity (12.7 cm/s). IVC: Inferior vena cava; LA: Left atrium; RA: Right atrium.