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Abstract

Introduction

Constrictive pericarditis is an uncommon cause of unilateral pleural effusion. In patient’s who have repeated thoracenteses with no obvious cause for the pleural effusion, constrictive pericarditis should be considered. Right and left heart catheterization is used to diagnosis constrictive pericarditis by measuring filling pressures of the heart.

Case Report

A 52-year-old man with a history of hepatitis C, hepatocellular carcinoma (HCC), status post liver transplant in July 2013, chronic kidney disease, gastroesophageal reflux disease and hypothyroidism presented with increasing dyspnea with minimal exertion and was found to have recurrent pleural effusion. Patient had been worked up as an outpatient for recurrent pleural effusion but no etiology had been found. Prior thoracentesis on three different occasions within a month had yielded exudative fluid with no evidence of malignant cells. The effusions re-accumulated within one week on each occasion. The patient had previously been treated with diuretics without resolution of his recurrent pleural effusion. With worsening of his renal function, diuretics had recently been discontinued. The patient denied shortness of breath at rest, cough and chest pain as well as fevers and chills. He also denied orthopnea and paroxysmal nocturnal dyspnea. Medications included tacrolimus, levothyroxine, omeprazole and a daily multivitamin. The patient has a history of prior alcohol abuse and prior tobacco use (10 pack years).

The patient’s vital signs were significant for mild tachypnea (20 respirations per minute) with normal oxygen saturation. He initially appeared healthy and in no acute distress. He had jugular venous distention. Pulmonary exam was clear on the left with decreased breath sounds in the right mid- and lower-lung fields. There was mild, bilateral lower extremity pitting edema.

The patient’s renal function was at his baseline (creatinine = 1.8 mg/dL, normal range 0.7 – 1.4). Complete blood count identified leukopenia, mild normocytic anemia, and thrombocytopenia. The patient’s labs identified elevated pro-brain natriuretic peptide (2511 pg/mL, normal range <125 pg/ml) and normal hepatic function panel except mildly elevated total bilirubin (1.3 mg/ dL, normal range 0.1 - 0.9 mg/dl). Chest X-ray in the Emergency Department identified a large right pleural effusion, increased from a study one week prior and associated right basilar atelectasis as well as a small left pleural effusion and background pulmonary edema. The patient was admitted and work-up for recurrent unilateral pleural effusion was initiated.

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