Beating outside the Box a case presentation on pericarditis. Kathryn R. Brim, DO, PGY1 Internal Medicine Resident

Transcription

1 Beating outside the Box a case presentation on pericarditis Kathryn R. Brim, DO, PGY1 Internal Medicine Resident

2 Presentation Mr. P.A. is a 47 year old male who presented to the emergency department with a chief complaint of sub-sternal chest pain.

3 History of Presenting Illness One week since onset Progressive sub-sternal chest pain Described as sharp/piercing Associated with exertion, radiation to L arm Typically < 20 minutes Relieved with rest Worsened with deep inspiration Occurs multiple times throughout the day Rates pain 6-9/10

4 Review of Symptoms Admits: Dyspnea on exertion, sharp substernal chest pain, radiation to the left arm, bilateral distal edema, 15lb weight gain, 5 pillow orthopnea, chronic MSK pain Denies: Headache, syncope, vision changes, nausea, vomiting, diaphoresis

5 Past Medical History Legg-Calve-Perthes syndrome Chronic migraine Obstructive sleep apnea Osteoarthritits Insomnia Vitamin D deficiency Erectile dysfunction Carpal tunnel syndrome, bilateral

6 Surgical History Left total hip arthroplasty Right total hip arthroplasty Knee surgery Knee arthroscopy Bilateral, carpal tunnel Elbow surgery Lung biopsy

7 Social History Former smokeless tobacco user, quit 2014 Alcohol use oz beers daily No illicit substances Sexually active Single Lives with parents, provides them assistance Employment: Supervisor rigging crew

8 Medications Colchicine 0.6 mg daily Vitamin D2 50,000 units weekly Oxycodone/apap 5/325 mg Q6H PRN Sildenafil 100 mg daily PRN Tamsulosin 0.8 mg QHS Tramadol ER 150 mg QD Trazodone mg QHS Zolpidem 10 mg QHS PRN

9 Physical Exam Vital Signs: BP 130/86 HR 75 Temp 36.9ᵒ C R 16 SpO2 98% BMI kg/m 2 Ht 6 1 Wt 90.7 kg (bed)

10 Physical Exam General: No acute distress HEENT: JVD to the angle of the mandible Cardiac: RRR, no murmur, intact distal pulses Pulm: no rales Abdomen: distension, soft, nontender Extremities: bilateral distal edema 2+ to knee, about iliac crests, sacral edema - anasarca

11 Initial Investigation CBC BMP GFR >60 LFT Protime/INR 15.7 / 1.2 Troponin T < 0.01 < 0.01 Lipid 156 t A1c 5.4 EKG: sinus bradycardia, 59 bpm, low amplitude

12 Recent labs from PCP D-Dimer < ESR < 15 CRP 0.8 BNP 1,344 ANA Reflex Panel Negative

13 Previous Work-up CCP negative ( ) RF negative ( ) ANA Reflex negative ( )

14 Emergency Room Course Administered 324 mg ASA Lasix 20 mg IV once Oxycodone 5/325 mg once Sublingual nitroglycerin once Admitted for observation Additional studies ordered: Echocardiogram Chest x-ray

15 Chest X-Ray 1. Left basal linearity and blunting of the left costophrenic angle, stable 2. Cardiomegaly

16 Chest X-Ray

17 CT Chest without contrast 1. Pericardial calcifications 2. Fibrotic changes at the lung bases including rounded density at the left medial lung base 3. Pleural thickening without effusion

18 CT Chest - Image

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23 Echocardiogram Conclusions: 1. Normal LV size, LV systolic function 2. Septal bounce with septal shift during respiratory cycle 3. EF 60% 4. Abnormal LV diastolic function 5. Biatrial enlargement 6. Abnormal filling pressures 7. Significant elevated right atrial pressure >15 mmhg, RVSP 34 mmhg

24 Echocardiogram - Images

25 Left/Right Heart Catheterization Typical diastolic equalization of filling pressures consistent with constrictive pericarditis. Discordant R & L ventricular pressures. Normal coronary arteries

26 Catheterization Hemodynamics LA 15/16 LV 85/3 98% AO 83/52 RA 12/9 RV 37/4 98% PA 34/14

27 Additional Lab Evaluation ANA with reflex panel Negative Anticardiolipin IgG Negative Anticardiolipin IgA Negative Anticardiolipin IgM Negative QuantiFeron Gold TB - Negative

28 Hospital Course At this point Diuresis, net 6 L Marked symptomatic improvement More euvolemic on exam New appreciable apical knock PIP synovitis, erythema All imaging studies consistent with constrictive pericarditis Unclear etiology

29 Discharge Referral to Stanford for pericardiectomy Currently he is still awaiting final evaluation

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31 Etiology? Tuberculosis low risk, ruled out Post viral unclear, though no viral pro-drome, remote history of unexplained prior pericarditis Post MI normal coronary vessels without evidence on imaging No history of radiation No history of prior CT surgery Idiopathic - potentially

32 Occam s Razor vs. Hickam s Dictum

33 My Proposal for Occam A unifying diagnosis for Mr. P.A. presentation may be lsssc

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