Clinical Cases: Pericardial disease39Diagnostic difficulties of a vasculitis caused by uncommon cardiovascular manifestation40Pericardial mass in a post-surgery mitral endocarditis patient41Focal constrictive pericarditis: multimodality imaging

# 39 Diagnostic difficulties of a vasculitis caused by uncommon cardiovascular manifestation {#article-title-2}Although pericardial effusion is a common finding in the echocardiographic laboratory, in many of the cases the etiology remains unexplored. Sometimes, by careful investigation, a treatable condition can be diagnosed.A 68-year-old woman was admitted to our hospital with a one-year-long history of dyspnea on exertion, leg swelling and dull chest pain. The patient lost 30 kg of weight in a year. The year before, due to her difficulty with breathing, our patient spent a day in an emergency department, where a chest CT was performed, which described an intramural haematoma of the ascending aorta. In the same period, hoarseness occurred. The otorhinolaryngological examination diagnosed left-sided recurrent nerve paralysis. The patient history included bilateral cataract, however, after cataract extraction, the patient remained blind to the left eye. At evaluation, her erythrocyte sedimentation rate was 52 mm/hour, the six-minute walk test supported the decreased physical activity. Transthoracic echocardiography revealed dilated ascending aorta and moderate pericardial effusion. Transoesophageal echocardiography showed thickened ascending aortic wall and aortic arch. Chest CT-angiography confirmed the concentric thickening; however, the descending aorta was not affected. The autoimmune serology showed ANCA-positivity with markedly elevated proteinase 3. Coronary CT angiography revealed that the thickened aortic wall caused a 40% stenosis in the proximal part of the right coronary artery and found a thickening of the pulmonary trunk wall along with the pulmonary arteries. The carotid ultrasound depicted a mass around the central part of the right common carotid artery. These findings were suggestive of both large vessel vasculitides and granulomatosis with polyangiitis. The case was complicated by difficulties in the radiologic differentiation of the intramural haematoma and the aortic wall infiltration. The location of the vascular involvement made the biopsy technically impossible. The diagnostic dilemma was dissolved by an ophthalmologic examination, which revealed left-sided anterior ischemic optic neuropathy. Regarding the involvement of the great arteries, the patient’s age, and the ophthalmological complication, giant cell arteritis was diagnosed. After three months of therapy, control echocardiography showed no pericardial effusion, the patient began to gain weight and the chest pain disappeared.In spite of the rare occurrence of pericardial effusion and Ortner’s syndrome in giant cell arteritis, a precise evaluation can lead to the diagnosis and a specific therapy, by which the development of an aortic aneurysm rupture can be prevented. ![Figure][1] Abstract 39 Figure.# 40 Pericardial mass in a post-surgery mitral endocarditis patient {#article-title-3}Purulent pericarditis is a rare condition (u003c1%), which results from haematogenous spread, direct spread from an adjacent infectious focus, trauma, or surgery. It usually presents with diffuse involvement of the whole pericardium, but can rarely present as a localized effusion. We present a case of a black 26 years old male with HIV (maternal transmission), and HIV nephropathy on haemodialysis, admitted to our hospital due to fever, vomit and diarrhoea of 5 days duration. Additional workup revealed: bacteraemia caused by methicillin-resistant Staphylococcus aureus and negative coproculture. Despite vancomycin treatment, fever and inflammatory parameters elevation persisted and he developed heart failure. The transthoracic echocardiogram (TTE) showed a large vegetation and aneurism of the posterior leaflet of the mitral valve, causing severe mitral regurgitation. He was submitted to emergent surgery and a mechanical prosthetic mitral valve was implanted. This was complicated by a Klebsiella pneumoniae nosocomial infection. During more than one month postoperatively, despite treatment with vancomycin and meropenem, and resolution of the pneumonia, he maintained tachycardia, lower limb oedema, low-grade fever and persistent inflammatory parameters elevation (CRP 10 mg/dL). The TTE and transoesophageal echocardiogram (TOE) at 2 and 3 weeks postoperatively showed no signs of prosthetic endocarditis, but a moderate pericardial effusion, which didn’t improve on haemodialysis. The TTE one week later demonstrated a posterior, lateral and anterior loculated pericardial effusion with multiple adhesions and signs of constrictive pericarditis. Inside the pericardial space an oval circumscribed collection (4,5x 3,2 mm) compatible with a pericardial abscess was found. A new TOE revealed its close relation with the left atrial appendage, but still no signs of annulus abscess or prosthetic endocarditis. The patient was referred for urgent surgical drainage of the effusion and abscess and pericardiectomy.Pericardial abscess is a rare and life-threatening illness associated with a high mortality. The usual signs and symptoms of pericarditis may be absent, thus masking the diagnosis. An early echocardiogram is recommended for the correct and timely diagnosis and treatment. Antibiotics and drainage remains the best treatment for improving the prognosis in these patients. ![Figure][1] Abstract 40 Figure.# 41 Focal constrictive pericarditis: multimodality imaging {#article-title-4}A fifty year old man was evaluated because of paroxismal atrial fibrilation with frequent crisis. He had no cardiovascular risk factors. His past history was noteworthy only for bladder surgery that did not require oncology treatment. The echocardiography revealed an echodense mass that produced external compression at the right atrioventricular groove, systemic congestion, anomalous septal motion and restrictive left ventricular diastollic filling. A cardiac magnetic resonance (CMR) was then performed. This showed an hypointense mass at that place on T1- and T2- weighted spin echo an cine. In contrast, it showed enhancemente after contrast administration. A cardiac tomography (CT) confirmed the focal calcification at the atrioventricular groove and focal constrictive pericarditis was diagnosed.Our report shows a mass unmasked in the evaluation of atrial arrythmias. The evaluation of cardiac masses comprises several imaging tests. Echocardiography is the first step. In allows morphologic and dynamic assesment, but relies on acustic window ando multiplane visualization is not possible. CMR overcome this limitation offering the same information, apart from perfusion, late enhancement and tissue characterization. But significant calcium deposits can be missed. And enhancemente suggest blood supply or communication with cardiac chambers. It also can occur because of residual inflammation. Finally, CT has better spatial resolution ant is the most appropiate to detect calcium.As a conclusion, our report underscores the importance of multimodality imaging. There is no one-stop shop to depict cardiac masses and each technique offers complementary information. ![Figure][1] Abstract 41 Figure. [1]: pending:yes