Canadian Journal of Cardiology
Images in Cardiology| Volume 32, ISSUE 3, P395.e11-395.e12, March 2016

Perimyocarditis Complicated by Early Development of Constrictive Pericarditis

      A 54-year-old man with a history of type 1 diabetes mellitus and hyperthyroidism presented with typical symptoms of pericarditis after an episode of flu-like symptoms. His electrocardiogram revealed diffuse ST-T segment elevation not confined to an arterial territory. Plasmatic levels of cardiac troponin remained within normal values. Treatment with nonsteroidal anti-inflammatory drugs was initiated, but he presented with recurrent symptoms and progressive dyspnea several weeks later. Further evaluation revealed a history of frequent purulent nasal discharge. Urine analysis demonstrated microhematuria. Echocardiography revealed a thickened pericardium without effusion, augmented respiratory variation of mitral inflow (Fig. 1A), normal medial peak E′ velocities (Fig. 1B), and abnormal septal motion during diastole (septal bounce). Cardiac magnetic resonance imaging showed marked pericardial thickening on cine, T1-, T2-weighted, and delayed enhancement (DE) imaging (Fig. 1, D-F), with diastolic septal bounce on cine imaging (see Videos 1 and 2; view videos online) compatible with constriction.
      • Cosyns B.
      • Plein S.
      • Nihoyanopoulos P.
      • et al.
      European Association of Cardiovascular Imaging (EACVI) position paper: multimodality imaging in pericardial disease.
      On T2-weighted and DE imaging, the hyperintense visceral and parietal pericardium were clearly discernable. Midwall linear hyperintensity in the basal inferolateral segments complemented the diagnosis of acute perimyocarditis. Endomyocardial biopsies did not show active myocarditis or granuloma formation on histology. Additional immunohistological analysis revealed borderline leukocyte infiltration (13 CD45-positive inflammatory cells per mm2; Fig. 1C) and an increased parvovirus-B19 viral load (319 copies per microgram DNA) in polymerase chain reaction assay. A serology test showed the presence of perinuclear-antineutrophil cytoplasmic antibody (ANCA) (titer: 1/128) confirmed with proteinase 3-capture enzyme-linked immunosorbent assay and a marked increased soluble interleukin-2 (5587 pg/mL), consistent with granulomatosis with polyangiitis (formerly known as Wegener granulomatosis).
      Figure thumbnail gr1
      Figure 1(A) Pulsed wave Doppler signal of mitral inflow with > 25% respiratory variation of peak E velocity; (B) tissue Doppler signal with normal medial peak E′ velocities; (C) CD45 immunostaining shows borderline myocardial leukocyte infiltration (arrows); (D) thickened pericardium on diastolic still frame on cine; (E) T2-weighted black-blood turbo spin-echo with fat suppression; and (F) delayed enhancement (DE) images. Visceral (arrows) and parietal pericardium (arrows) show increased signal intensity on (E) T2-weighted and (F) DE images, with focal linear, midwall hyperintensity on the DE images, compatible with acute perimyocarditis.
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