Prevalence and significance of gallium-67 uptake in the heart after open-heart surgery

Radioactive gallium-67 (Ga-67) has been shown to accumulate within areas of pericardial inflammation. The present study estimated prospectively the prevalence and clinical significance of Ga-67 uptake in the heart in 62 patients 10 to 16 days after open-heart surgery. Of 62 patients studied, markedly diffuse Ga-67 uptake was detected in 21 (34%) and focal or mild diffuse uptake in 23 (37%). Results were negative in 18 (29%). Nine patients with a negative scan result (50%) had received corticosteroid therapy before imaging, whereas only 2 patients with a positive scan result (5%) were receiving steroids. The erythrocyte sedimentation rate and C-reactive protein level were both higher in patients with Ga-67 uptake compared with those with a negative scan result (p less than 0.01 in both). No other clinical, echocardiographic or electrocardiographic indicators of postpericardiotomy syndrome were related to Ga-67 uptake. No patient developed cardiac tamponade or constrictive pericarditis during the 12-week follow-up and the Ga-67 scan results did not predict the occlusion of coronary artery bypass grafts. Thus, pericardial inflammation manifested as Ga-67 uptake is a common finding after open-heart surgery and appears to be a benign condition.     

Pericardial disease in patients with cancer: The differentiation of malignant from idiopathic and radiation-induced pericarditis

Pericardial disease developed in 31 patients with a variety of malignancies. Half of the patients (58 percent) were found to have malignant pericardial involvement, 32 percent idiopathic pericarditis and 10 percent radiation-related pericarditis. Facial swelling, cardiac arrhythmias and pericardial tamponade occurred frequently in the patients with malignant pericardial disease. Fever, pericardial friction rub and improvement with nonsteroidal anti-inflammatory drugs characterized the patients with idiopathic pericarditis. Effusive-constrictive pericarditis requiring pericardiectomy was noted in patients with radiation-induced disease. Pericardiocentesis documented malignant pericardial disease in 85 percent of patients studied, while 15 percent required open biopsy for diagnosis. Specific therapy directed at malignant pericardial disease may contribute to survival up to one year in 25 percent of patients. In 40 percent of patients with idiopathic pericarditis and in the majority of patients with radiation-induced pericarditis, survival was one year with specific therapy. A systematic evaluation of pericardial disease will benefit a subset of cancer patients with idiopathic pericarditis and radiation-induced pericarditis who can be managed conservatively.     

Pericardial involvement in acute myocardial infarction

The incidence of both early postinfarction pericarditis and post-myocardial infarction (Dressler's syndrome) appears to be declining. Pericardial pain and pericardial friction rub define early postinfarction pericarditis and usually develop on day 2 or 3 after a transmural myocardial infarction. The clinical course is benign, and the prognosis of the patient is not altered by development of this complication. Pericardial effusions have been found in as many as 28% of patients after acute MI. Asymptomatic pericardial effusions do not require specific therapy nor do they absolutely contraindicate the use of anticoagulation as was previously thought. The preferred form of therapy for early postinfarction pericarditis is aspirin. Avoidance of corticosteroids and NSAIDs must be considered carefully because of the reported complications of these agents. The post-myocardial infarction syndrome develops usually during the second or third week after acute MI but may be seen as early as 24 hours and as late as several months after the MI. Whether this syndrome is the result of autosensitization to myocardial antigens released into the circulation during infarction remains uncertain. Alternative hypotheses for the causation of the syndrome include the release of blood in the pericardial space and simply that the syndrome represents a prolonged and exaggerated form of early postinfarction pericarditis. Clinically, post-myocardial infarction syndrome is manifested by fever, malaise, chest pain, and the presence of a pericardial and possibly pleuropericardial friction rub. Pericardial effusion is frequently large, and, rarely, cardiac tamponade may develop and require pericardiocentesis. Treatment consists of aspirin, NSAIDs, or corticosteroids.(ABSTRACT TRUNCATED AT 250 WORDS)     

Constrictive pericarditis in procainamide-induced lupus erythematosus syndrome

A rare case of constrictive pericarditis in procainamide-induced lupus erythematosus syndrome is reported. After 6 months of procainamide therapy fever, pleuritic chest pain, arthralgia and muscle soreness developed in a 47 year old man. These symptoms were soon followed by the onset of acute pericarditis and rapidly accumulating massive pericardial effusion. After withdrawal of procainamide therapy and administration of corticosteroids in large doses, there was marked subjective improvement and rapid reduction in pericardial effusion. However, constrictive pericarditis with massive leg edema and ascites developed 6 weeks after admission as corticosteroid therapy was gradually discontinued. These manifestations subsided after pericardiectomy was performed.     

Pericarditis and Pericardial Effusion: Management Update

Prompt recognition of the signs and symptoms of pericardial disease is critical so that appropriate treatments can be initiated. Acute pericarditis has a classical presentation, including symptoms, physical examination findings, and electrocardiography abnormalities. Early recognition of acute pericarditis will avoid unnecessary invasive testing and prompt therapies that provide rapid symptom relief. Non-steroidal anti-inflammatory drugs (NSAIDs) remain first-line therapy for uncomplicated acute pericarditis, although colchicine can be used concomitantly with NSAIDS as the first-line approach, particularly in severely symptomatic cases. Colchicine should be used in all refractory cases and as initial therapy in all recurrences. Aspirin should replace NSAIDS in pericarditis complicating acute myocardial infarction. Systemic corticosteroids can be used in refractory cases or in those with immune-mediated etiologies, although generally should be avoided due to a higher risk of recurrence. Pericardial effusions have many etiologies and the approach to diagnosis and therapy depends on clinical presentation. Pericardial tamponade is a life-threatening clinical diagnosis made on physical examination and supported by characteristic findings on diagnostic testing. Prompt diagnosis and management is critical. Treatment consists of urgent pericardial fluid drainage with a pericardial drain left in place for several days to help prevent acute recurrence. Analysis of pericardial fluid should be performed in all cases as it may provide clues to etiology. Consultation of cardiac surgery for pericardial window should be considered in recurrent cases and may be the first-line approach to malignant effusions, although acute relief of hemodynamic compromise must not be delayed. Constrictive pericarditis is associated with symptoms that mimic many other cardiac conditions. Thus, correct diagnosis is critical and involves identification of pericardial thickening or calcification in association with characteristic hemodynamic alterations using noninvasive and invasive diagnostic approaches. Constrictive physiology may occur transiently and resolve with medical therapy. In chronic cases, definitive therapy requires referral to an experienced surgeon for pericardiectomy.     

Colchicine in Treatment of Intractable Postpericardiotomy Syndrome in an Elderly Patient

Postpericardiotomy syndrome is a specific type of acute pericarditis because of a delayed pericardial and/or pleural reaction after thoracic surgery. Relapse after aspirin, nonsteroidal anti-inflammatory drug, and/or steroid treatment or intractable to this conventional therapy causes a troublesome situation. Colchicine was first proposed for treatment of recurrent pericarditis in 1987. A number of investigators have reported the efficacy and safety of colchicine in combination therapy for recurrent pericarditis. Recently, Colchicine for Recurrent Pericarditis and Colchicine for Acute Pericarditis studies suggested that colchicine is useful in the first attack of acute pericarditis, and corticosteroid therapy given in the first attack favors the recurrence of pericarditis. In this report, we present an 82-year-old woman with severe tricuspid regurgitation and moderate-to-severe mitral regurgitation because of rheumatic heart disease, postpericardiotomy syndrome with severe pleural and pericardial effusion developed after the open-heart surgery. Both pleural and pericardial effusion was intractable to steroid therapy. Colchicine and steroid combination therapy made the syndrome remission rapidly. The total course of colchicines therapy was 2.5 months. There was no recurrence after 1 year of clinic follow-up.     

Neoplastic pericarditis--the role of different diagnostic procedures

The aim of the study was to assess the role of different diagnostic procedures in the recognition of malignant pericarditis. Consecutive medical records of the patients with pericardial effusion treated with pericardiocentesis or pericardioscopy in the period of 1982-2002 were analyzed retrospectively. Criteria of neoplastic pericarditis were: positive result of pericardial fluid cytology and/or neoplastic infiltration found in pericardial biopsy specimen. Criteria of non-neoplastic pericarditis were: negative result of pericardial fluid cytology and pericardial biopsy specimen, no neoplastic disease diagnosed at presentation and during 3-years of follow up. Malignant pericarditis was diagnosed in 47 patients (pts), nonmalignant in 51. Echocardiographic signs of cardiac tamponade were found in 80% of pts with neoplastic pericarditis and 40% of pts with non-malignant disease (p = 0.0001). Chest CT scan revealed the presence of enlarged mediastinal lymph nodes in 94% of pts with malignant pericarditis and only 11% of pts with non-malignant disease (p = 0.00001). Pericardial thickness on CT scan exceeded 8 mm in 75% of the pts with malignant pericarditis and 8% of pts with nonmalignant disease (p = 0.0003). Pericardial fluid (pf) CEA concentration was significantly higher in the patients with neoplastic pericarditis than in the pts with non-malignant process. CEA > 5 ng/ml and Cyfra 21-1>50 ng/ml were found in 43% of the pts with malignant pericarditis and none of the pts with benign pericarditis. Thus we recommend chest CT scan and pericardial fluid tumor markers (CEA and Cyfra 21-1) assessment as the procedures helpful in the recognition of malignant pericarditis.     

Steroid treatment deteriorated ventricular tachycardia in a patient with right ventricle-dominant cardiac sarcoidosis

We report a case of a patient with cardiac sarcoidosis presenting with a non-sustained ventricular tachycardia (VT), mimicking arrhythmogenic right ventricular cardiomyopathy. After the pathological diagnosis and confirmation of gallium-67 uptake by the myocardium, corticosteroid therapy was initiated. The myocardial gallium accumulation disappeared shortly after the treatment, but the VTs deteriorated into multifocal and sustained VTs almost all day. Those drug-refractory VTs were finally controlled with 3 catheter ablation sessions.     

Meningococcemia without meningitis presenting as cardiac tamponade. Survival with disseminated intravascular coagulation

Pericardial effusion is an unusual complication of meningococcal meningitis in this modern era of antibiotics, and to date only one case of meningococcal pericarditis without meningitis has been reported. Our patient presented as a case of cardiac tamponade of unknown origin without meningitis. Moreover, he survived the frequently fatal complication of disseminated intravascular coagulation which occurred in the absence of shock. Two weeks after the onset of myopericarditis, corticosteroids were administered for a persistent pericardial effusion, with good response. Other cases of meningococcal pericardial effusion treated with corticosteroids are discussed.     

Chronic Pericarditis and Pericardial Tamponade Associated with Ulcerative Colitis

Unlike other extraintestinal inflammatory manifestations of ulcerative colitis, cardiac involvement is infrequently reported and inadequately characterized, with only 9 previously reported cases of pericardial tamponade associated with inflammatory bowel disease. A 32 year old male with ulcerative colitis, treated with orally administered mesalamine for ten years, developed chronic pericarditis. Extensive clinical and laboratory evaluation failed to find any cause of the pericarditis other than the ulcerative colitis. Although the pericarditis remitted with indomethacin therapy, this medicine had to be discontinued because of a reactivation of ulcerative colitis attributed to this nosteroidal antiinflammatory drug (NSAID). The pericarditis then responded well to high-dose corticosteroid therapy, but the patient represented with chest pain, dyspnea, tachypnea, and engorged neck veins after tapering the corticosteroid therapy. Angiography revealed near equalization of end diastolic pressures in both ventricles, a finding consistent with pericardial tamponade. The patient underwent subtotal pericardiectomy. Thoracotomy revealed a thickened pericardial wall and a large pericardial effusion. The patient's symptoms resolved postpericardiectomy. This case extends the clinical spectrum of pericarditis associated with ulcerative colitis, by describing a case of pericarditis that was chronic, refractory to maintenance medical therapy, caused pericardial tamponade, and was successfully treated by pericardiectomy.     

Churg-Strauss syndrome revealed by granulomatous acute pericarditis: two case reports and a review of the literature

BACKGROUND: Churg-Strauss syndrome (CSS) is a necrotizing systemic vasculitis with extravascular granulomas and eosinophilic infiltrates of small vessels. CSS is usually revealed by nonspecific signs of necrotizing vasculitis in a context of late-onset asthma and blood eosinophilia. It is considered a systemic vasculitis with the highest prevalence of cardiac involvement and can lead to rapid-onset heart failure due to specific cardiomyopathy. Pericardial effusion may also occur during CSS and is usually well tolerated. OBJECTIVE: The objective of these case reports was to indicate that CSS may present as tamponade, with or without other visceral involvement. METHODS: Among CSS patients treated during the past 10 years at 2 French university hospitals, we have identified and described 2 cases revealed by tamponade with pericardial biopsy-proven granulomatous vasculitis. We have also reviewed the international medical literature in PubMed on cardiac involvement in CSS. RESULTS: The first case report describes a 66-year-old man who had an isolated cardiac tamponade with both inflammatory syndrome and eosinophilia. Long-term remission was obtained with corticosteroids. The second case report describes a 46-year-old woman whose CSS presented with tamponade and associated central nervous system and myocardial involvement. Remission was obtained with corticosteroids and cyclophosphamide. In both cases, CSS was assessed by histological analysis of a pericardial sample. CONCLUSIONS: CSS may present as isolated cardiac tamponade. Whereas pericarditis with myocardial injury warrants immunosuppressive therapy, isolated pericarditis without other visceral involvement of poor prognosis only requires corticosteroid therapy.     

Constrictive pericarditis as complication of viral respiratory infection

A 24 year-old man with 3-months medical history of recurrent respiratory infections and pericardial effusion, despite treatment with nonsteroid anti-inflammatory drugs, was admitted to the hospital with dyspnea on exertion. On admission he presented the symptoms of right heart insufficiency. Computed tomography of the chest demonstrated a thickened pericardium. Echocardiographic examination and right heart catheterisation established the diagnosis of constrictive pericarditis. Serologic tests suggested viral aetiology. The patient was referred to cardiothoracic surgery, partial pericardiectomy was performed with marked haemodynamic improvement.     

Clinical value of gallium-67 SPECT scintigraphy in the diagnostic and therapeutic evaluation of retroperitoneal fibrosis: a prospective study

BACKGROUND: Gallium-67 (67Ga) scintigraphy may be useful in evaluating patients with retroperitoneal fibrosis (RPF), but a systematic assessment of its value is lacking. OBJECTIVE: Prospective evaluation of the value of 67Ga scintigraphy in assessing active RPF disease and in predicting treatment response. METHODS: Thirty-four patients with nonmalignant RPF treated with tamoxifen underwent 67Ga scintigraphy at baseline and--if baseline gallium scan was positive--at 3 months follow-up. Gallium scans were visually scored according to pathologic 67Ga-uptake compared to normal bone marrow 67Ga-uptake. Results were correlated with other (follow-up) measurements. Value of (follow-up) 67Ga scintigraphy in predicting treatment response was also assessed. RESULTS: Gallium scans were positive in 24 patients (71%). Mass thickness was greater in patients with positive gallium scan compared with patients with negative gallium scan (P = 0.006). Visual gallium score correlated with mass thickness (P = 0.006). Visual gallium score decreased significantly following tamoxifen treatment (P < 0.0001). Decrease in visual gallium score correlated with decreases in C-reactive protein and erythrocyte sedimentation rate (P = 0.019) and with decrease in mass thickness (P < 0.01). Positive predicting value (PPV) of positive baseline gallium scan was 0.71; PPV of negative follow-up gallium scan in patients with initial positive scan was 0.89. 67Ga scintigraphy detected extra-abdominal involvement in one patient and recurrent active disease in two symptomatic patients with normal acute-phase reactants and stable residual mass. CONCLUSION: 67Ga scintigraphy is useful in assessing (recurrent) activity of RPF disease and in evaluating treatment response in patients with initial positive gallium scan.     

Recurrent pericarditis

Recurrent pericarditis is the most troublesome complication of pericarditis occurring in 15 to 30% of cases. The pathogenesis is often presumed to be immune-mediated although a specific rheumatologic diagnosis is commonly difficult to find. The clinical diagnosis is based on recurrent pericarditis chest pain and additional objective evidence of disease activity (e.g. pericardial rub, ECG changes, pericardial effusion, elevation of markers of inflammation, and/or imaging evidence of pericardial inflammation by CT or cardiac MR). The mainstay of medical therapy for recurrent pericarditis is aspirin or a non-steroidal anti-inflammatory drug (NSAID) plus colchicine. Second-line therapy is considered after failure of such treatments and it is generally based on low to moderate doses of corticosteroids (e.g. prednisone 0.2 to 0.5 mg/kg/day or equivalent) plus colchicine. More difficult cases are treated with combination of aspirin or NSAID, colchicine and corticosteroids. Refractory cases are managed by alternative medical options, including azathioprine, or intravenous human immunoglobulins or biological agents (e.g. anakinra). When all medical therapies fail, the last option may be surgical by pericardiectomy to be recommended in well-experienced centres. Despite a significant impairment of the quality of life, the most common forms of recurrent pericarditis (usually named as “idiopathic recurrent pericarditis” since without a well-defined etiological diagnosis) have good long-term outcomes with a negligible risk of developing constriction and rarely cardiac tamponade during follow-up. The present article reviews current knowledge on the definition, diagnosis, aetiology, therapy and prognosis of recurrent pericarditis with a focus on the more recent available literature.     

Pericarditis mediated by respiratory syncytial virus in a hematopoietic stem cell transplant patient

We describe a case of pericarditis and large pericardial effusion in a 63‐year‐old African‐American man undergoing autologous hematopoietic stem cell transplant for multiple myeloma. Pericardial tissue biopsy demonstrated fibrinous pericarditis, and immunohistochemistry stains were positive for respiratory syncytial virus. The patient improved with oral ribavirin and intravenous immune globulin infusions.     

Pericardial effusion and mitral valve involvement in systemic lupus erythematosus. Echocardiographic study.

Echocardiography was used in 30 women and 2 men with systemic lupus erythematosus (SLE) in order to determine the incidence and severity of pericardial effusion and mitral valve involvement. 31 patients showed normal thickness of the mitral valve leaflets, only one patient showed irregular thickening of the leaflets suggesting the presence of vegetations. Mitral valve motions were normal in all patients. These results indicate that myocardial and valvular involvement in SLE is usually not severe enough to result in haemodynamic abnormalities. Pericardial effusion was found in 2 patients who were symptom free, whereas 4 of the patients with a past history suggestive of pericarditis showed no echocardiographic evidence of pericardial effusion. These suggest the transient nature of pericarditis in SLE, and the value of echocardiography as a diagnostic tool in detecting clinically inapparent lupus pericarditis.     

Transient Constrictive Pericarditis: Current Diagnostic and Therapeutic Strategies

Transient constrictive pericarditis is increasingly recognized as a distinct sub-type of constrictive pericarditis. The underlying pathophysiology typically relates to impaired pericardial distensibility, associated with acute or sub-acute inflammation, rather than the fibrosis or calcification often seen in chronic pericardial constriction. Accordingly, patients may present clinically with concomitant features of pericarditis and constrictive physiology. Non-invasive multimodality imaging is advocated for diagnosis of transient constrictive pericarditis. Echocardiography remains the mainstay for initial evaluation of the dynamic features of constriction. However, cardiac magnetic resonance imaging can provide complimentary functional information, with the addition of dedicated sequences to assess for active pericardial edema and inflammation. Although transient pericardial constriction can spontaneously resolve, institution of anti-inflammatory therapy may hasten resolution or even prevent progression to chronic pericardial constriction. Non-steroidal anti-inflammatory agents remain the initial treatment of choice, with subsequent consideration of colchicine, steroids, and other immune-modulating agents in more refractory cases.     

Quantitative gallium scanning in pulmonary sarcoidosis

Pulmonary parenchymal involvement in sarcoidosis is due to noncaseating granuloma, fibrosis or both. To assess the granulomatous activity in pulmonary sarcoidosis, we performed gallium-67 citrate scans in 41 patients with sarcoidosis and in 13 non-sarcoid patients, who were free of pulmonary disease and served as controls. Gallium score, a measure of gallium accumulation in lung parenchyma, was obtained from the sum of activity indices (ratio of accumulated gallium activity over a chest quadrant and soft tissues of the mid-thigh) from each of the quadrants over the anterior and posterior aspects of the chest. The gallium score in patients with sarcoidosis was significantly higher than the gallium score in controls. The gallium scores in patients with sarcoidosis, with radiographically apparent pulmonary infiltrate were significantly higher than the scores in the patients with no radiographic evidence of pulmonary parenchymal involvement. The gallium scores in patients not receiving corticosteroids were significantly higher compared to patients who were receiving corticosteroids, and furthermore, the gallium scores fell significantly when corticosteroids were initiated. There was a significant correlation between serum angiotensin-converting enzyme (SACE) activity and gallium score. In 11 patients, 27 sequential gallium scans were performed and changes in gallium score correlated well with the changes in SACE activity and clinical assessment. These findings suggest that quantitative evaluation of gallium scans may be useful in assessing granulomatous activity of pulmonary sarcoidosis and following its response to therapy.     

Pneumococcal pericarditis. Diagnostic usefulness of counterimmunoelectrophoresis and computed tomographic scanning

Although counterimmunoelectrophoresis (CIE) analysis of cerebrospinal fluid has proved useful in the diagnosis of meningitis, there has been little experience with its use in analyzing pericardial fluid. We describe two patients with pneumococcal pneumonia whose hospital course was complicated by purulent pericarditis. In one patient, results of a computed tomographic scan were important in suggesting the diagnosis. Results of a Gram's stain and culture of pericardial fluid failed to yield any organisms, presumably because both patients had received nine days of beta-lactam antibiotic therapy. However, the results from CIE analysis of pericardial fluid in both cases were positive for Streptococcus pneumoniae. In one patient, for whom capsular typing of the organism was performed, the pneumococcus type isolated from pericardial fluid matched the type isolated previously from a blood sample. The results of CIE can allow focused antibiotic therapy by establishing the correct diagnosis.     

A case of rheumatoid pericarditis associated with a high IL-6 titer in the pericardial fluid and tocilizumab treatment

We report a 60-year-old woman with rheumatoid arthritis complicated by pericarditis. Treatment with tocilizumab improved her polyarthritis, but the pericardial effusion increased so rapidly as to cause cardiac tamponade before the treatment could prove its efficacy. Pericardial effusion disappeared after pericardiocentesis. The pericardial fluid contained a remarkably high concentration of interleukin-6 (IL-6; 351,000 pg/mL), which tocilizumab appeared to have made yet higher compared to the reported IL-6 levels in rheumatoid pericarditis. No further exacerbation of pericarditis was observed after retreatment with tocilizumab. This case has important implications in that it suggests that the prominently elevated IL-6 level in pericardial fluid during tocilizumab treatment may be an indicator of its efficacy for pericarditis.