Radiation-Induced Pericarditis: Imaging and Management
History of Presentation
A 65-year-old female with stage 1 invasive ductal carcinoma breast cancer, treated with lumpectomy in September 2021 with adjuvant anastrozole chemotherapy and radiation therapy starting in November 2021, presented with pleuritic chest pain. Her pain first started in January 2022 after receiving 16 sessions of radiation treatment and she had multiple emergency department visits for recurrent chest pains. The pain was sharp in nature, located primarily in the left chest, radiated to the left arm, and was exacerbated by movement and change in position. She experienced a significant decrease in her activity level because of the pain. She also endorsed palpitations and shortness of breath but denied orthopnea, paroxysmal nocturnal dyspnea (PND), dizziness, syncope, and leg swelling. Previous workup included persistently elevated inflammatory markers and a computed tomography (CT) scan of the chest which showed post-radiation fibrosis and scarring in the left upper and lower lobes, minimal scarring in the right lobe, a left pleural effusion, and a new moderate, circumferential pericardial effusion. Patient had been taking prednisone 10 mg daily and colchicine 0.6 mg twice daily without resolution of her symptoms. Physical exam showed a normotensive patient with regular rate and rhythm, no friction rub or pericardial knock, no murmurs, and no jugular vein distention (JVD). Patient did not have peripheral edema and had grade 2/4 distal pulses bilaterally.
Past Medical History
Other medical history was pertinent for hypertension, hyperlipidemia, coronary artery calcifications and paroxysmal atrial fibrillation. She denied any history of cardiac surgeries, autoimmune conditions, tuberculosis, or recent viral infections.
Laboratory studies were pertinent for negative Westergren sedimentation rate of 13 mm/hr, negative C-reactive protein of <0.3 mg/dL, elevated N-terminal prohormone brain natriuretic peptide (NTproBNP) of 1,138 pg/mL, and slightly elevated high sensitivity troponin T of 22 ng/L. Electrocardiogram showed sinus rhythm at a rate of 60 beats per minute, normal axis, normal intervals, and non-specific T-wave inversions in the inferior leads. Echocardiogram showed no evidence of pericardial effusion or constrictive physiology, normal left ventricular systolic and diastolic function with ejection fraction of 65%, normal right ventricular systolic function, and no significant valvular abnormalities. Cardiac magnetic resonance imaging (CMR) showed mildly increased pericardial thickness measuring 4 mm without pericardial effusion, moderate pericardial late gadolinium enhancement (LGE) and mild pericardial edema on T2 weighted, no evidence of constrictive physiology, normal biventricular size, and systolic function with no myocardial delayed enhancement to indicate prior ischemic damage or interstitial fibrosis (Figure 1). Patient was thus diagnosed with pericarditis, likely radiation induced.
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