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Answers on p 355.
A 50 year old woman was referred by her general practitioner for investigation of a six month history of dry cough, intermittent night sweats, and arthralgia affecting the wrist joints. Two weeks before her appointment she had noticed exertional breathlessness, mild ankle swelling, and flitting chest pains. There was no other past medical history and she was not taking any drugs. On examination she was pyrexial (37.6°C) and both wrist joints were warm and painful to move (no other joints were affected). Other abnormal findings were a slightly raised jugular venous pressure, quiet heart sounds, and mild ankle oedema. Her chest was clear, abdominal examination unremarkable, and there was no rash. A chest radiograph showed cardiac enlargement (fig 1A) with clear lung fields and she was admitted for further investigations.
While an inpatient she had a spiking pyrexia up to 38°C. Full blood count showed haemoglobin concentration 118 g/l, white cell count 7.9 × 109/l with normal differential, and the erythrocyte sedimentation rate (ESR) was 25 mm/hour. Liver function tests were normal apart form a mildly raised alanine aminotransferase of 44 IU/l. An echocardiogram showed a large pericardial effusion which was drained with some improvement in her cough. Two weeks later worsening chest pains, recurrence of cough, and malaise led to further investigations. She now had a daily spiking fever up to 40°C, usually in the evening, which returned to normal or below normal. ESR had risen to 110 mm/hour and haemoglobin had dropped to 97 g/l. The white cell count was 11.4 × 109/l with a neutrophilia of 9.8 × 109/l. Repeat echocardiogram did not show any pericardial fluid reaccumulation but a further chest radiograph showed moderate left and right pleural effusions (fig1B).
- What are the common causes of pleuropericardial effusion?
- What further investigations are necessary in this patient's case?
- The patient's symptoms and radiology returned to normal after treatment with aspirin 3.6 g daily. What is the likely diagnosis?