|Number 10-24: Acute Idiopathic Pericarditis|
Number 10-24: Acute Idiopathic Pericarditis
Authors: Bratis K (1), Mavrogeni S (2), Potsios D (1), Mitropoulou E (1), Mpoutos G (1), Mantzouratos D (1)
Institution: (1) Cardiology Department, Patision General Hospital, Athens, Greece & (2) A' Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece
Case: A 58-year old man, free from any previous medical history, presented to the emergency department with retrosternal oppressive chest pain, varying with inspiration and posture, of rapid installation and evolution after prolonged direct exposure to cold airflow from an air-conditioner.
Despite an initial normal clinical examination and a modest inflammatory profile as the only laboratory finding, the hypothesis of acute pericarditis arose. Echocardiography was strictly normal (Figure 2 - apical four-chamber end-diastolic view; Figure 3 - parasternal long-axis view).
Figures 2 & 3 [right click mouse to enlarge]
A CT scan (Fig. 4) was urgently performed - pending the availability of CMR imaging - which depicted a thickening of the pericardium, without pericardial effusion but with mild bilateral pleural effusion.
Figure 4 [right click mouse to enlarge]
CMR was then performed. LV end-diastolic volume (164mL) and ejection fraction (64%) were normal, as assessed by cine balanced SSFP imaging (Movie 1, four-chambers view).
Short -inversion recovery T2-weighted imaging with fat suppression demonstrated hyperintense signal from the pericardium (arrowed in Fig. 5), particularly sensitive for tissue oedema, a substantial feature of an acute inflammation reaction. There was neither myocardial oedema, nor pericardial effusion.
Contrast-enhancement inversion recovery imaging before contrast administration (Fig. 6), and in the late phase after gadolinium injection (Fig. 7), showed a significant circumferential homogenous thickening of both visceral and parietal pericardium, measuring approximately 7mm, with significant contrast enhancement, which may be due to severe oedema and/or cellular necrosis. There was no evidence of late contrast myocardial enhancement, permitting thus to exclude any associated myocardial fibrosis or acute myocarditis.
Figures 6 & 7
A symptomatic treatment with non steroid anti inflammatory drugs (ibuprofen 800 mg per os three times daily) was initiated with a gratifying response and complete relief of the symptoms from the second dose of NSAID.
We describe a case of acute idiopathic pericarditis, in which diagnosis was based mainly on the clinical findings, and confirmed by advanced imaging techniques. Beside the rarity of similar images in the literature (3, 4) we find quite intriguing the fact that in an era of intense debate on the competitive role of the various cardiac imaging exams, this case delinates a condition in which conventional techniques, like echocardiography, fail to contribute to the diagnosis. Cardiac CT and CMR with the use of tissue characterisation techniques, permit the acquisition of high quality images depicting inflammation, leading to the confirmation of a diagnosis known till now to derive on exclusion.
COTW Handling Editor: Monica Deac