Imaging Divulged What Signs and Symptoms Didn’t: Acute Pericarditis
Shortness of breath in an 85-year-old man posed a diagnostic challenge. He presented with a 2-month history of progressively worsening dyspnea on exertion. Over the previous week, he also experienced orthopnea and bilateral lower-extremity edema. He denied chest pain or recent febrile illness. His medical history included heart failure with preserved systolic function and hypothyroidism. He was a nonsmoker, and his family history was not significant.
On presentation, he had a temperature of 99.3° F (37.4° C), heart rate of 87 beats per minute, blood pressure of 124/62 mm Hg, and respiratory rate of 20 breaths per minute. Physical examination revealed mildly distended jugular veins, bilateral basal lung crackles, normal heart sounds without murmurs, rubs, or gallops, and 2+ symmetric bilateral lower-extremity edema.
The patient’s history and physical findings were consistent with decompensated heart failure. Intravenous diuretic therapy was started. A 12-lead electrocardiogram (ECG) showed normal sinus rhythm with right bundle branch block (Figure 1). A chest x-ray demonstrated an enlarged cardiac silhouette with left pleural effusion. This was further investigated with transthoracic echocardiography, which disclosed a moderate-sized pericardial effusion without evidence of tamponade physiology; the left-ventricle ejection fraction was preserved (Figure 2– shown above).
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— Tarun Jain, MD, Mushabbar A. Syed, MD
This article originally appeared in the May 2013 issue of The American Journal of Medicine.
