Abstract: This case report presents a 60-year-old gentleman with a significant smoking history and possible asbestos exposure who was referred to the emergency department for atrial fibrillation with a rapid ventricular rate and symptoms of heart failure. Labs showed normal brain natriuretic peptide and troponin I. His echocardiography finding suggested constrictive pericarditis with an ejection fraction of 60%. A computed tomography scan was concerning for a pericardial mass. Left and right heart catheterization hinted more toward constrictive physiology; however, some findings were concerning for restrictive physiology. Hence, cardiac magnetic resonance imaging was done, which established the diagnosis of constrictive pericarditis. Pericardiectomy was planned with a maze procedure for atrial fibrillation. However, a malignant neoplasm was seen on a frozen biopsy. Hence, surgery was limited to partial pericardiectomy, as the patient had advanced infiltrative neoplasm that had resulted in constrictive pericarditis. The final pathology report confirmed the diagnosis of malignant pericardial mesothelioma mixed type. Malignancy is usually diagnosed in an advanced stage, like in our case, due to nonspecific initial presentation. A literature review suggests that there is a lack of established consensus on treatment. The response to therapy also seems to be poor and results only in palliation of symptoms, with a median survival of six months from diagnosis despite optimum medical management.
Introduction: Malignant mesotheliomas are rare tumors in body cavities covered by mesothelium. The pleura is the most common site of its occurrence. However, it can also arise in other body sites like the peritoneum, pericardium, or tunica vaginalis of the testis [1]. Hillerdal et al. performed a large review of 4710 cases and reported that pericardial mesotheliomas accounted for only 0.7% of all mesotheliomas [2]. We report a rare case of primary pericardial mesothelioma presenting as constrictive pericarditis.
Case Presentation: A 60-year-old gentleman was referred to the emergency department after being found to be in atrial fibrillation with a rapid ventricular rate. He had a significant past medical history of chronic diastolic heart failure, permanent atrial fibrillation, and alcoholic cirrhosis. He is an active smoker with a 40-pack-year smoking history and a retired construction worker with reported asbestos exposure. On presentation, the patient complained of orthopnea, increased shortness of breath (New York Heart Association (NYHA) class 3), increased leg swelling, and palpitations over the last several weeks. He stated that he had gained 10 pounds unintentionally in the previous month. He denied chest pain, cough, nausea, dizziness, syncope, and fevers. His home medications included Eliquis, lasix, spironolactone, and metoprolol, with which he reported compliance. He denied any illicit drug use and had quit drinking six months ago. Of note, he reported having undergone a pericardial window for pericardial effusion a year ago at an outside facility.
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