Q&A Medicine>>>>>Cardiology
Question 59#

A 42-year-old man presents to the hospital with worsening leg swelling and exertional dyspnea. He denies any recent illness, fevers, weight loss, cough, chest pain, or abdominal pain. His medical history is significant for Hodgkin lymphoma at the age of 20, and he has been in remission after treatment with chemotherapy and radiation. He does not smoke or drink alcohol, and he denies any recent travel or new environmental exposures. His vitals are normal, and there is no scleral icterus or cervical lymphadenopathy. The jugular venous pressure is elevated and increases further during inspiration. Heart sounds are distant with no S3, and the lungs are clear bilaterally. There is hepatomegaly and pitting edema of the lower extremities. A chest x-ray shows a normal heart border without any pulmonary infiltrates. An echocardiogram is performed that shows normal wall thickness with no significant pericardial effusion.

Which of the following is the most likely diagnosis?

a. Pulmonary hypertension
b. Dilated cardiomyopathy
c. Restrictive cardiomyopathy
d. Constrictive pericarditis

Correct Answer is D

Comment:

Constrictive pericarditis. Patients with previous radiation therapy to the chest are at risk for constrictive pericarditis, which is a result of thickening and decreased compliance of the pericardium. Any cause of acute pericarditis can progress to constrictive pericarditis. These patients present with symptoms of right-sided heart failure and Kussmaul sign, which is a paradoxical increase in jugular venous pressure during inspiration. (C) Kussmaul sign can also be seen in restrictive cardiomyopathy; however, the echocardiogram did not show an increase in myocardial wall thickness and therefore the more likely diagnosis is constrictive pericarditis. (A) Pulmonary hypertension may cause right-sided heart failure but would not present with Kussmaul sign. (B) There are many causes of dilated cardiomyopathy, including radiation exposure; however, Kussmaul sign should lead the reader to think of constrictive pericarditis. In addition, the chest x-ray did not show an enlarged heart.