Constrictive pericarditis in Primary Hyperparathyroidism: An unusual presentation
A Iqbal, B Inayat, N Haya, The Great Western Hospital NHS Trust Foundation Swindon
Abstract: The classic symptoms of primary hyperparathyroidism have evolved considerably and ranges from no symptoms to minimal symptoms. We present a case of 81 years old man who presented with signs & symptoms of heart failure (pedal edema, shortness of breath). Examination revealed elevated JVP, pulses paradoxus, pericardial knock, decreased breath sounds and pedal edema. Chest x-ray showed right pleural effusion & pericardial calcification. Laboratory investigations showed hypercalcemia with low serum phosphate level and raised PTH level. CT scan of the neck, parathyroid sestamibi scan findings were consistent with parathyroid adenoma. Echocardiography, CT thorax showed constrictive pericarditis due to pericardial calcification and bilateral pleural effusion. Patient was treated with pamidronate for hypercalcemia and diuretics for heart failure. On his second presentation with high calcium level, pamidronate, cinacalcet and alendronic acid were given. On third admission with heart failure, patient was treated with diuretics and had upper normal calcium.
Hyperparathyroidism is associated with multiple clinical and biochemical abnormalities, but its role in heart disease is not clear. There is strong evidence that these patients have increased risk of death due to cardiovascular disease. Hyperparathyroidism can cause hypertension, left ventricular hypertrophy, coronary artery disease, valvular calcification, myocardial calcific deposits and arrhythmias. Although risk of constrictive pericarditis in end stage renal disease induced hypercalcemia is known in few case reports. We present a case of patient who developed constrictive pericarditis secondary to primary hyperparathyroidism, as we feel it is important to highlight the possibility of constrictive pericarditis in these cases.
All Other causes of constrictive pericarditis were considered, detailed history for various causes, clinical signs and number of tests were done to exclude other causes.
This patient with complex presentation was managed by multidisciplinary team including endocrinologist, cardiologist and ENT surgeon. His symptoms of heart failure improved with medical therapy. Multidisciplinary cardiology meeting decided that he will not be a candidate for pericardectomy or pericardial stripping. After multidisciplinary meeting with ENT and Endocrine surgeons, it was decided that in a view of his constrictive pericarditis patient will not be a good candidate for surgical intervention.