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| CASE REPORT |
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| Year : 2023 | Volume
: 21
| Issue : 2 | Page : 120-122 |
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A case of transient constrictive pericarditis following COVID-19 infection
Omar Fakhreddine, Jamil Francis, Joe Younes, Walid Gharzeddine
American University of Beirut Medical Center, Beirut, Lebanon
| Date of Submission | 08-Nov-2022 |
| Date of Decision | 07-Dec-2022 |
| Date of Acceptance | 09-Dec-2022 |
| Date of Web Publication | 07-Apr-2023 |
Correspondence Address:
Dr. Omar Fakhreddine
American University of Beirut Medical Center, Beirut
Lebanon
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_119_22
With the emergence of the novel severe acute respiratory syndrome coronavirus 2 as a global pandemic, the cardiovascular system was considered one of the major systems affected by this virus. Here, we report the case of a 62-year-old male, who was diagnosed with COVID-related pericarditis, presenting with worsening chest pain and shortness of breath, with echocardiographic findings suggestive of early-stage constrictive pericarditis.
Keywords: Constrictive pericarditis, pericarditis, severe acute respiratory syndrome coronavirus 2
How to cite this article:
Fakhreddine O, Francis J, Younes J, Gharzeddine W. A case of transient constrictive pericarditis following COVID-19 infection. Curr Med Issues 2023;21:120-2 |
How to cite this URL:
Fakhreddine O, Francis J, Younes J, Gharzeddine W. A case of transient constrictive pericarditis following COVID-19 infection. Curr Med Issues [serial online] 2023 [cited 2023 Jun 4];21:120-2. Available from: https://www.cmijournal.org/text.asp?2023/21/2/120/373754 |
| Introduction | |  |
Since the emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a global pandemic back in 2019, and as the number of survivors was increasing, a wide range of post-COVID sequelae was detected. The cardiovascular system is considered one of the major systems affected by this virus. Cases of myocarditis, pericarditis, cardiac fibrosis, endothelial dysfunction, arrhythmias, thrombotic events, and dysautonomia were all reported in the literature as COVID-19-associated cardiovascular complications.
Patients with preexisting cardiovascular disease are at higher risk, but there are reports of younger patients with no known comorbidities presenting with concerning cardiac manifestations.[1]
The underlying pathophysiology of COVID-19-associated cardiovascular complications is not fully understood, although direct viral infection of the myocardium and cytokine storm has been suggested as possible mechanisms of myocarditis.[2]
Here, we report the case of constrictive pericarditis in the setting of COVID-19 infection after having obtained informed written consent from the patient.
| Case Report | | |
A 62-year-old man presented to the emergency department with chest pain and shortness of breath.
Medical history included dyslipidemia and hypertension, and the patient was taking rosuvastatin, ramipril, and bisoprolol.
Four weeks before the presentation, the patient was admitted to the hospital with a 2-day history of fever, rhinorrhoea, and cough. The SARS-CoV-2 polymerase chain reaction was positive. He was clinically and hemodynamically stable. Eventually, he was discharged home on paracetamol. Five days after discharge, he presented to the emergency department with low-grade fever and retrosternal chest pain that increases upon lying flat and improves when bending forward. A baseline electrocardiogram showed sinus tachycardia. A bedside echocardiography showed normal left ventricular systolic function with mild-to-moderate pericardial effusion and no signs of tamponade.
Laboratory tests were as follows: white blood cells – 15.1 × 103/mL, C-reactive protein – 218.4 mg/L, troponin – T 0.008 ng/mL (<0.030 ng/mL), and serum creatinine – 0.9 mg/mL. He was diagnosed to have acute pericarditis and was admitted for 24 h. He was later discharged home and advised to take ibuprofen 600 mg orally every 8 h and colchicine 0.5 mg orally twice daily.
Six days after discharge, the patient presented back to the emergency department with worsening chest pain and shortness of breath. On physical examination, he had no signs or symptoms of decompensated heart failure.
Laboratory studies showed: white blood cells – 11.5 × 103/mL, C-reactive protein – 82.6 mg/L, and troponin – 0.008 ng/mL. The electrocardiogram showed sinus tachycardia with no ST-T wave abnormalities.
Echocardiography showed a mild circumferential pericardial effusion with fibrinous material with no signs of tamponade. The inferior vena cava was dilated measuring 25 mm and not compliant with expiratory flow reversal in hepatic veins. There was evidence of septal bounce as well as exaggerated respiratory variation of mitral peak E-wave velocity by 36% [Figure 1], in addition to near equalization of the mitral annular lateral and medial e' [Figure 2]. | Figure 1: Respiratory variation of the mitral peak E- wave by about 36%.
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Based on these findings, the patient was diagnosed with early-stage constrictive pericarditis. He was switched from ibuprofen and colchicine to oral prednisone.
One month later, the patient presented for re-evaluation. He reported complete resolution of his shortness of breath and chest.
A transthoracic echocardiography showed normal inferior vena cava diameter and a reduction of the respiratory variation of the mitral peak E-wave velocity to 16%.
The patient eventually continued treatment with prednisone for 2 months to be tapered and discontinued after a total of 3 months.
| Discussion | | |
The patient in this case developed constrictive pericarditis a few weeks after his COVID-19-induced acute pericarditis. Based on his clinical course and imaging findings, he was diagnosed with this entity that is rarely described in the setting of COVID-19 infection.
Constrictive pericarditis is characterized by inflamed pericardium in addition to fibrotic thickening of the layers, inducing a restriction in cardiac fillings, and causing constrictive physiology. The usual causes of this pathology are postcardiac surgeries, tuberculous and purulent pericarditis, and radiation therapy, whereas viruses are rarely the culprit.[3]
In general, constrictive pericarditis is a late complication of chronic pericarditis.[4] In our case, it had a quicker evolution.
Many cardiac pathologies were reported associated with COVID-19 infection, namely myocarditis, arrhythmias, acute coronary syndromes, and even pericarditis.[5] However, few reported the event of constrictive pericarditis.
While the exact mechanisms of constrictive pericarditis following COVID-19 infection are not yet discovered, the systemic inflammatory state induced by the virus may play a major role in the occurrence of hard-to-control pericarditis. This process of ongoing underlying inflamed pericardium might hasten the formation of a constricted physiology. The presence of multiple fibrin deposition in the pericardium stresses this property of a highly inflammatory phenomenon, induced by the infection.
Despite the adequate management of acute pericarditis according to guidelines, symptoms were persistent, and findings of constrictive pericarditis developed. This might shed the light on a more aggressive regimen to control acute pericarditis in the setting of a COVID-19 infection and possible early administration of steroids, to prevent the development of constrictive pericarditis.
Medical therapy is still the mainstay of treatment of minimally symptomatic constrictive pericarditis. It consists mainly of colchicine and nonsteroidal anti-inflammatory drugs.[6] Unfortunately, many cases progress to the chronic stage requiring surgery by pericardiectomy as a definitive treatment.[7]
| Conclusion | | |
The cardiovascular system remains one the most commonly affected system by the novel SARS-CoV-2 with multiple cases of myocarditis, pericarditis, endothelial dysfunction, and sudden cardiac death has been reported. Transient constrictive pericarditis following COVID-19 infection is one of the rare cardiac complications which requires awareness as well as specific echocardiographic assessment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Srinivasan A, Wong F, Couch LS, Wang BX. Cardiac complications of COVID-19 in low-risk patients. Viruses 2022;14:1322.  |
| 2. | Farshidfar F, Koleini N, Ardehali H. Cardiovascular complications of COVID-19. JCI Insight 2021;6:e148980. |
| 3. | Diaconu R, Popescu L, Voicu A, Donoiu I. Subacute effusive-constrictive pericarditis in a patient with COVID-19. BMJ Case Rep 2021;14:e242443. |
| 4. | Syed FF, Schaff HV, Oh JK. Constrictive pericarditis – A curable diastolic heart failure. Nat Rev Cardiol 2014;11:530-44. |
| 5. | Bielecka-Dabrowa A, Cichocka-Radwan A, Lewek J, Pawliczak F, Maciejewski M, Banach M. Cardiac manifestations of COVID-19. Rev Cardiovasc Med 2021;22:365-71. |
| 6. | Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: The task force for the diagnosis and management of pericardial diseases of the European society of cardiology (ESC) endorsed by: The European association for cardio-thoracic surgery (EACTS). Eur Heart J 2015;36:2921-64. |
| 7. | Asif T, Kassab K, Iskander F, Alyousef T. Acute pericarditis and cardiac tamponade in a patient with COVID-19: A therapeutic challenge. Eur J Case Rep Intern Med 2020;7:001701. |
[Figure 1], [Figure 2]
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