The goal: among possible etiology of constrictive pericarditis, IgG4-related pericardial disease is an unusual cause of pericardial constriction.
Case report: 43-year-old male was admitted due to persistent right pleural effusion. Since 2021 he has been complaining of shortness of breath, fatigue, stomach and leg swelling and it was suspected heart failure. A year ago, he was examined for inguinal and retroperitoneal lymphadenopathy and due to ascites and liver enlargement liver cirrhosis was suspected. NP levels were mildly elevated (NT-proBNP 613 pg/mL), and on 12-lead electrocardiogram there were microvoltages. On echocardiography left heart size and LVEF were normal, right heart size and TAPSE were normal, VCI was dilated, incompressible, hepatic veins dilated, we found characteristic respiratory related shift of the septum (septal bounce), the lateral e’ velocity was lower than medial e’ velocity (annulus reversus). It was suspected constrictive pericarditis and on a CT scan there were heavy calcium deposits in the medioapical part of the pericardium of both ventricles. A rheumatologist performed an extensive immunological search for systemic disease due to elevated sedimentation rate (SE=56) and elevated IgE values, along with normal eosinophils. It was found elevated IgG- 4 (4.98 g/l, ref value 0.03-2.01) and diagnosis of IgG 4-related disease was established. The patient was put on intravenous corticosteroid therapy, but due to the current infectious disease (empyema pleurae), immunosuppressive therapy is at the moment contraindicated. Cardiac surgent has still been waiting for the resolution of pleural empyema and response to corticosteroids to make decision about possible pericardiectomy.
Conclusion: Constrictive pericarditis is not so common, and the evaluation of etiology should include immunological tests. (1)