Question

A 47 y/o male sees his physician complaining of shortness of breath, weakness and light-headedness. Px history shows that he had a ‘heart murmur’ during childhood. The physician notes that the Px has an irregular heartbeat with palpitations with active pulsing seen in the neck and pitting edema in the lower extremities. The physician refers the Px to the cardiovascular unit where he undergoes a chest X-ray, an ECG, an echocardiogram and finally a cardiac catherization where it is found he has regurgitation of the tricuspid valve. The Px undergoes a successful operation to replace the damaged valve with a bioprosthetic valve. However, 11 days after the operation, the Px has the same symptoms prior to surgery, but this time he is spiking a fever.

Based on these observations, what would your diagnosis be?

What further tests would you run to support your diagnosis?

Answer 1

the most likely diagnosis is Post-pericardiotomy syndrome.

Explanation

• Post-pericardiotomy syndrome (PPS) is seen after surgeries where pericardium is damaged.
• Example
  • Valve replacement surgery
  • coronary artery bypass surgery
  • Coronary stent placement
  • Repair of congenital heart anomalies like
    • tetralogy of Fallot
    • repair of the ventricular septal defect, atrial septal defect
    • cardiac transplantation
• This syndrome is autoimmune in nature
• These procedures lead to a release of cardiac antigens and the host immunity reacts to the antigens by producing antibodies.
• Helper T cell and cytotoxic T cell also play a role in post-pericardiotomy syndrome,

The clue to the diagnosis in this case is:

• History of cardiac surgery
• postoperative fever
• Fever occurred after 11 days. In PPS, fever develops within 1 - 6 weeks post-op
• Recurrence of breathlessness

Other symptoms that can be seen in PPS ( not giving in this case)

1. Malaise
2. chest pain
3. decrease appetite
4. Breathlessness

Sign

1. tachycardia
2. pericardial rub
3. pleural rub
4. edema

Diagnostic criteria for PPS is any 2 of the following:

1. fever without any other cause
2. Pericardial or pleural type of chest pain
3. Pericardial or pleural friction rub
4. evidence of pericardial effusion
5. Pleural effusion with elevated CRP

Test to be done to further confirm the diagnosis

• complete blood count - to look for leucocytosis - to rule out infection
• Blood culture - to rule out infection
• Chest Xray - to look for effusion
• ECG
  1. Finding in the initial stage is due to pericarditis - global ST-segment elevation and T wave inversion
  2. Myocardial inflammation - ST-segment elevation
  3. Stage of pericardial effusion - low amplitude qrs complex
• Echocardiography - to confirm the diagnosis of pericardial effusion
• Pleural fluid tapping -
  1. the fluid is exudative -the ratio of pleural fluid protein to serum protein = >0.5
  2. high LDH
  3. lymphocyte predominate
  4. normal glucose
  5. Adenosine deaminase levels < 35
  6. High CRP levels