Article, Oncology

Acute peritonitis as the first presentation of valvular cardiomyopathy

yielded a cloudy, straw-colored transudate with a protein content of 29 g/L, Neutrophil count of 80 cells per cubic millimeter, lactate dehydrogenase fluid to serum ratio of 0.17, glucose of 5.2 mmol/L, and scanty gram-positive bac- teria that did not culture. The patient was treated prophylac- tically with intravenous piperacillin and tazobactam, and started on spironolactone. Cytology reported reactive meso- thelial cells and a large number of lymphocytes. The dif- ferential diagnosis at this point included ovarian carcinoma, a reactive process, lymphoma, and tuberculosis. Computed tomographic of the abdomen reported small bilateral Pleural effusions with marked ascites but no solid nodules within the peritoneal cavity (Fig. 1A-C). Chest radiograph showed the heart size to be within normal limits (Fig. 1D). CA125 was raised at 201.3 kU/L; but ?-fetoprotein (1.3 kU/L), CA199 (20.7 kU/L), and CEA (2.2 ug/L) measurements were all within normal limits. Both abdominal and transvaginal ultrasound examinations showed normal ovaries at this time; and following gynecologic consultation, it was agreed that the raised CA125 value was due to peritoneal stretch and shedding of mesothelial cells into the ascitic fluid [1].

Reexamination of the patient at this point revealed a raised jugular venous pressure and a grade 2 pansystolic murmur that radiated to the left axilla. Tender hepatomegaly was elicited, and there was evidence of persistent bibasal lung effusions.

At this point, an echocardiogram was performed. It demonstrated that all cardiac chambers were dilated with a global decrease in contractility. There was severe mitral, tricuspid, and aortic regurgitation, with an ejection fraction of 42%. A diagnosis of cardiomyopathy with acute heart failure, secondary to valvular heart disease, was secured. Cardiac catheterization showed Normal coronary arteries with mild elevation of pulmonary artery pressures. Right ventricular systolic pressure was 38 mm Hg, and the pul- monary capillary wedge pressure was 14 mm Hg. The patient was commenced on an angiotensin-converting enzyme inhibitor and a ?-blocker, and was transferred to the national center for cardiothoracic surgery where she underwent aortic and Mitral valve replacements. Her postoperative recovery was uneventful. She is attending a cardiac reha- bilitation program and at latest follow-up is symptom-free.

The diagnosis of cardiomyopathy is established in the setting of left ventricular dilation and systolic dysfunction (an ejection fraction b50%) [2]. Cardiomyopathy, owing to any cause, usually culminates in congestive cardiac failure

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image of Fig. 1247.e6 Case Report

Fig. 1 Computed tomographic images representing (A) bilateral pleural effusions, (B) free fluid in pelvis, and (C) perihepatic fluid. (D) Posteroanterior chest radiograph showing cardiac contour within normal limits.

(CCF), of which one of the manifestations is ascites. Ascites has been reported as a presenting feature of cardiomyopathy [3], and Spontaneous bacterial peritonitis in the setting of long-standing CCF has previously been observed [4]. However, acute peritonitis as the presenting feature of valvular cardiomyopathy is a previously unreported clinical entity. It is postulated that our patient had underlying valvular heart disease that was exacerbated by her Viral illness. These 2 insults then precipitated acute CCF with associated ascites that culminated in peritonitis.

Nikki Higgins MB BCh BAO NUI

Department of Cardiology St. Vincent’s University Hospital

Dublin 4, Ireland E-mail address: [email protected]

John P. Burke PhD Department of Surgery St. Columcille’s Hospital Loughlinstown, Co.

Dublin, Ireland

Charles J. McCreery MD

Department of Cardiology St. Vincent’s University Hospital

Dublin 4, Ireland

doi:10.1016/j.ajem.2010.09.019

References

  1. Silberstein LB, Rosenthal AN, Coppack SW, Noonan K, Jacobs IJ. Ascites and a raised serum Ca 125–confusing combination. J R Soc Med 2001;94(11):581-2.
  2. Hunt SA. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2005;46(6):e1-e82.
  3. Kronzon I, Fedor M, Schwartz D, Gallo G, Jacobson DR. A 58-year-old man with shortness of breath, ascites, and leg edema. Circulation 1996;94(6):1483-8.
  4. Bulger K, Sugrue D, Crowe J. Spontaneous bacterial peritonitis in cardiac ascites: a case report. Ir J Med Sci 1987;156(11):333.