Authors: Lee Bockus, Kenta Nakamura, Michael A Chen
Published: 2024-04-23
DOI: 10.1161/circ.144.suppl_1.9307
Source: Full article
A case of rare cholesterol pericarditis that developed over 12 years resulting in a massive pericardial effusion containing cholesterol crystals is described. A 41-year-old homeless man with history of polysubstance intravenous drug abuse and upper respiratory and soft-tissue infections presented with evidence of recurrent left lower extremity cellulitis, mild shortness of breath, and palpitations. Physical exam demonstrated soft-tissue infection, marked tachycardia and distant heart sounds on auscultation, and jugular venous distention. Unexpectedly, pulse-oximetry plethysmographic waveforms revealed pronounced respirophasic variability and pulsus paradoxus of 14 mmHg. Electrocardiogram demonstrated low voltage and electrical alternans. A transthoracic echocardiogram revealed a large pericardial effusion and findings consistent with tamponade physiology, such as elevated respiratory variation in mitral inflow velocity. Emergent pericardiocentesis yielded 3.6 L of fluid characterized by glittering, gold paint-like appearance and a cell count predominated by macrophages, leading to a provisional diagnosis of cholesterol pericarditis. This was confirmed by polarized light microscopy demonstrating cholesterol crystals. Retrospective review of prior emergency department visits revealed a 12-year development of the effusion, beginning with symptoms, imaging, and labs consistent with a presumably instigating viral respiratory illness. Over time, progressive enlargement and evidence of chronic pericarditis were demonstrated by chest x-ray and electrocardiography, while the effusion remained undiagnosed. Following improvement in his symptoms after pericardiocentesis, the patient deferred pericardial window and definitive surgical management with pericardiectomy. Given his high risk for recurrent cardiac tamponade, he was given clear return precautions and is now followed on an outpatient basis. The diverse etiologies of cholesterol pericarditis, such as hypothyroidism, tuberculosis, and rheumatoid arthritis, that guided the workup for this patient, and the pathophysiology of this disease and its treatment options, are reviewed.