Qida borusu xərçəngi ilə əlaqəli eksudativ-konstriktiv perikardit: Pnevmoperikardla müşayiət olunan təngnəfəsliyin nadir səbəbi

Şəxanə Ələsgərli; Anar  Kərimxanov; Mətin  Hədidzadə; Gulay Məmmədova

doi:10.28942/acj.v28i2y2026.146

Abstrakt

Eksudativ-konstriktiv perikardit, perikard effuziyasının uyğun olmayan, qalınlaşmış perikardla birlikdə mövcud olduğu və tamponada və daralma xüsusiyyətlərini birləşdirən hibrid hemodinamik şəkil yaradan nadir bir perikardial sindromdur. Bədxassəli şişlərlə əlaqəli perikardial xəstəlik yaxşı tanınır, lakin qida borusu karsinoması ilə əlaqəli olaraq ortaya çıxan eksudativ-konstriktiv proses, pnevmoperikardiyanın radioloji sübutları ilə birlikdə olduqca nadirdir və birbaşa şiş invaziyası və ya özofagus-perikardial fistula ehtimalını artırır. Biz, iki illik qida borusu karsinoması tarixçəsi olan və qida borusu stentlənməsi ilə müalicə olunan və mütərəqqi gərginlik zamanı nəfəs darlığı və perikard daralmasının klinik əlamətləri ilə müraciət edən 73 yaşlı bir qadının vəziyyətini bildiririk. Fiziki müayinə, laboratoriya müayinəsi, exokardioqrafiya və ürək maqnit rezonans görüntüləməsi, əlaqəli septal sıçrayışla eksudativ-konstriktiv perikardit diaqnozunu qoydu, döş qəfəsinin kompüter tomoqrafiyası isə əlavə olaraq perikarddaxili havanı göstərdi. Xəstə onkologiya qrupu ilə əlaqələndirilmiş şəkildə perikardiektomiya da daxil olmaqla çoxsahəli tibbi və cərrahi yanaşma ilə müalicə edildi. Bu hal, qida borusu bədxassəli şişi olan bir xəstədə nadir, potensial olaraq həyati təhlükə yaradan nəfəs darlığının səbəbini aşkar etməkdə multimodal görüntüləmənin və sistematik klinik müayinənin diaqnostik dəyərini vurğulayır.

Əsas mətn

Introduction

Pericardial disease encompasses a broad spectrum of conditions with heterogeneous etiologies, and it can occasionally present with unusual or overlapping phenotypes. Exudativeconstrictive pericarditis is one such hybrid entity, characterized simultaneously by pericardial fluid accumulation and by a stiffened, poorly compliant pericardium that impairs diastolic filling. This combination poses particular diagnostic and therapeutic challenges, since the coexistence of effusive and constrictive physiology can mask or mimic other cardiac and noncardiac conditions.

When exudative-constrictive pericarditis develops in the setting of malignancy, it is even less common, and its occurrence in association with esophageal carcinoma is rarely reported. Esophageal cancer may involve the pericardium either through direct local invasion or through the formation of an esophago-pericardial fistula, both of which can result in constrictive remodeling of the pericardium. The additional finding of intrapericardial air is highly atypical and should prompt consideration of a communicating tract between the esophagus and the pericardial space or of another superimposed pathological process. We present a case that is notable both for its rare oncologic etiology and for the unusual clinical and imaging findings that guided its diagnosis and management.

Case report

A 73-year-old woman with a two-year history of esophageal carcinoma, previously managed with endoscopic esophageal stent placement and maintained under regular oncologic followup, presented to the cardiology outpatient clinic with progressively worsening dyspnea and a sensation of choking. Symptoms were most pronounced during physical exertion, although they were also reported at rest in some episodes.

Physical examination

On presentation, the patient was hypotensive (blood pressure 90/70 mmHg), with a regular pulse of 93 beats per minute, oxygen saturation of 94% on room air, a temperature of 37.0 °C, and a respiratory rate of 19 breaths per minute. General inspection revealed jugular venous distension, peripheral edema, and pallor with generalized weakness. Palpation demonstrated hepatomegaly and epigastric tenderness. Percussion disclosed widened cardiac dullness together with findings suggestive of pleural effusion. On auscultation, heart sounds were muffled without a pericardial friction rub, and bilateral basal crackles were present.

The clinical picture was notable for Beck's triad — hypotension, jugular venous distension, and muffled heart sounds — together with a positive Kussmaul's sign (a paradoxical rise in jugular venous pressure on inspiration, characteristic of constrictive pericarditis) and pulsus paradoxus exceeding 10 mmHg. These findings, taken together, were highly suggestive of a pericardial process with a constrictive component and prompted urgent further cardiac evaluation.

Initial electrocardiographic and laboratory evaluation

The initial electrocardiogram demonstrated STsegment elevation in several leads, which initially raised concern for an acute coronary syndrome. However, the overall clinical picture and subsequent investigations, including a negative troponin, were not consistent with acute myocardial ischemia, and coronary angiography was undertaken to exclude significant obstructive coronary artery disease as the driver of the presentation.

Laboratory investigations are summarized in Table 1. Leukocytosis and a markedly elevated C-reactive protein indicated an active inflammatory process involving the pericardium, while a negative troponin argued against acute myocardial infarction and supported a pericardial origin for the electrocardiographic changes. NTproBNP was substantially elevated, consistent with the hemodynamic burden imposed by pericardial constriction, and normocytic anemia was attributed to anemia of chronic disease in the context of the underlying malignancy.

Diagnostic workup

Transthoracic echocardiography identified an exudative-type pericardial effusion surrounding the posterior and lateral walls of the heart, together with paradoxical interventricular septal motion — a septal bounce — a finding that increased suspicion for an underlying constrictive pericardial process.

To further characterize the pericardial pathology, cardiac magnetic resonance imaging was performed, which confirmed the diagnosis of constrictive pericardial disease, demonstrating pericardial thickening together with concomitant effusion and fibrotic change. Chest computed tomography, obtained earlier in the diagnostic pathway, had already revealed the presence of air within the pericardial space. This finding of pneumopericardium was considered highly atypical and raised concern for a pathological communication between the esophagus and the pericardium, or for direct tumoral invasion of the pericardial space; other rare underlying mechanisms were also considered.

Integration of the clinical history, physical examination, laboratory results, echocardiographic findings, cardiac MRI, and CT imaging supported a diagnosis of exudative-constrictive pericarditis related to esophageal carcinoma. The case illustrated that no single imaging modality was sufficient in isolation, and that an accurate diagnosis was only reached through the combined, stepwise use of electrocardiography, echocardiography, CT, and cardiac MRI.

Diagnosis and management

The final diagnosis was exudative-constrictive pericarditis related to esophageal carcinoma. Initial medical management targeted the inflammatory pericardial process and its hemodynamic and infectious complications. This included colchicine (1 g once daily) and ibuprofen (400 mg three times daily) for anti-inflammatory control of the pericarditis, together with pantoprazole (40 mg once daily) for gastric protection. Empiric intravenous antibiotic therapy was started with vancomycin (1 g once daily) from day 1 to day 4, after which therapy was switched to teicoplanin (400 mg once daily) based on clinical assessment. Rate control was achieved with metoprolol (25 mg twice daily), and volume status was managed with furosemide (20 mg three times daily) and spironolactone (25 mg once daily), while enoxaparin (0.6 mL twice daily) was administered for thromboprophylaxis.

Given the constrictive component of the disease and the underlying malignant etiology, a multidisciplinary approach was adopted, including consultation with cardiothoracic surgery, coordinated with the patient's oncology team, in line with current recommendations for the management of pericardial disease. Surgical pericardiectomy (pericardial stripping) was performed as the definitive intervention to relieve pericardial constriction and restore hemodynamic function. Postoperative echocardiography demonstrated resolution of the pericardial effusion and improvement in the patient's hemodynamic status, with corresponding clinical improvement in dyspnea.

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