WBR0023

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Author Raviteja Reddy Guddeti MBBS, Aarti Narayan MBBS (Edited by Will GIbson)
Exam Type USMLE Step 3
Main Category Emergency Room
Sub Category Infectious Disease, Cardiovascular, Infectious Disease
Prompt A 65 yr old male with a past medical history of tuberculosis presents to the clinic concerned about progressive shortness of breath for the past few months. He also complains of weakness, fatigue, and weight gain during this period. Physical examination shows increased abdominal girth, bilateral pedal edema, hepatomegaly and an increase in jugular venous pressure on deep inspiration. Cardiac auscultation reveals an extra diastolic heart sound. Chest X-ray demonstrates calcification in the precordial area and EKG shows diffuse low voltage QRS complexes with flattened T waves. What is the most appropriate initial therapy for this patient?
Answer A Pericardiocentesis
Answer A Explanation [[AnswerAExp::Incorrect: Pericardiocentesis refers to the removal of fluid within the pericardial space by aspiration. While pericardiocentesis is the appropriate treatment for a pericardial effusion, this patient has constrictive pericarditis. Constrictive pericarditis is often characterized by calcification and fibrosis, but not fluid accumulation. Thus, there is no fluid to remove and pericardiocentesis is ineffective for constrictive pericarditis.]]
Answer B Pericardial resection
Answer B Explanation Correct: Pericardial resection is necessary for the treatment of constrictive pericarditis. However, diuretics should be administered first to acutely relieve the symptoms of heart failure. Because diuretic therapy was not an option in this question, pericardial resection is the next best answer.
Answer C Beta blockers
Answer C Explanation [[AnswerCExp::Incorrect: Beta blockers are not indicated for the treatment of constrictive pericarditis.]]
Answer D Antituberculous therapy
Answer D Explanation Incorrect: While antitubercular therapy is indicated for the treatment of constrictive pericarditis secondary to tuberculosis, pericardial resection should be performed first.
Answer E Glucocorticoids
Answer E Explanation [[AnswerEExp::Incorrect: Glucocorticoids are indicated for pericarditis secondary to a chronic inflammatory process such as systemic lupus erythematosis. In contrast, non-recurrent pericarditis caused by viral infections or myocardial infarction should be treated with NSAIDs or aspirin respectively.]]
Right Answer B
Explanation [[Explanation::This patient has constrictive pericarditis as a result of chronic tuberculosis infection. Constrictive pericarditis occurs when a fibrotic or calcified, adherent pericardium restricts diastolic filling of the right side of the heart. It is most commonly caused by conditions or events that cause inflammation to develop around the heart, including: tuberculosis, radiation therapy, or neoplastic infiltration. Patients will often present with signs of right heart failure including edema, ascites, or jugular venous distention. Physical exam findings commonly include a positive Kussmaul's sign (increase of JVD on inhalation) and a pericardial knock (the sound produced by blood hitting a rigid ventricle during diastole). Constrictive pericarditis must be differentiated from restrictive cardiomyopathy. Imaging studies showing calcification strongly favor the diagnosis of constrictive pericarditis, while cardiomegaly favors the diagnosis of restrictive cardiomyopathy. Electrocardiography and echocardiography can also help distinguish the two (see: Constrictive pericarditis differential diagnosis).

Constrictive pericarditis should be treated with diuretics followed by pericardial resection. Diuretics should be administered prior to surgery to acutely relieve the symptoms of heart failure. The pericardium is then resected to allow the heart to relax effectively during diastole, and thereby relieve symptoms of systemic and pulmonary congestion.

Educational Objective: Pericardial resection is necessary for the treatment of constrictive pericarditis.

References: Master the Boards Step 2 CK 2013 page 101
Educational Objective:
References: ]]

Approved Yes
Keyword Pericarditis, Constrictive pericarditis, Pericardium, Tuberculosis, TB, Heart failure
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