A 63-year-old man presents to his primary care physician for evaluation of fatigue, shortness of breath while walking, and swelling in his legs, which have gotten worse over the last several months. Past medical history is significant for radiation therapy to the base of the neck 10 years ago for squamous cell carcinoma. Physical examination reveals peripheral edema in the legs, hepatomegaly, and mild ascites. Chest radiograph reveals pericardial calcifications.
Which of the following additional features is most likely present in this patient?
C) Kussmaul sign
This patient has constrictive pericarditis, a condition in which granulation tissue formation in the pericardium results in loss of pericardial elasticity which impairs venous return to the right side of the heart. Pericardial calcifications, seen on this patient’s chest x-ray, are usually seen in patients with a history of pericarditis and may be associated with constrictive pericarditis. Signs and symptoms of constrictive pericarditis include dyspnea, fatigue, peripheral edema, and ascites. Kussmaul sign is the paradoxical increase in jugular venous pressure on inspiration due to impaired filling and backup into the venous system.
Answer choice A: Audible S3 heart sound, is incorrect. This typically reflects fluid overload and enlarged ventricular chambers. It is more frequently associated with patients who have dilated cardiomyopathy and/or severe mitral regurgitation, though it can also be present in athletes and during pregnancy. An S3 heart sound is typically low pitched, while a pericardial knock is typically high pitched.
Answer choice B: Biventricular enlargement, is incorrect. Constrictive pericarditis is more likely to cause biatrial enlargement.
Answer choice D: Pericardial knock in early systole, is incorrect. Although a pericardial knock can be heard in constrictive pericarditis, it is an early diastolic sound.
Answer choice E: Proteinuria, is incorrect. Although proteinuria leading to hypoalbuminemia can cause peripheral edema and ascites, this patient’s history of radiation therapy and chest x-ray findings make constrictive pericarditis a more likely cause of his symptoms.
Key Learning Point
Constrictive pericarditis may present with the Kussmaul sign, a paradoxical rise in jugular venous pressure during inspiration due to impaired filling of the right side of the heart.
