Case Presentation: A 77-year-old woman with a history of recent pacemaker implantation for sick sinus syndrome presented to the ED with progressively worsening fatigue, shortness of breath, fevers, and chest pain. She was previously admitted for similar symptoms two weeks prior and, at that time, symptoms were thought to be secondary to acute diastolic heart failure. She was treated with diuretics and discharged when symptomatically improved.
Exam on subsequent admission showed normal vital signs and was significant only for absent breath sounds over the left lung base.
A CT (computerized tomography) of the chest revealed a large left sided pleural effusion and a moderately sized pericardial effusion. A thoracentesis yielded pleural fluid consistent with an exudative process. Transthoracic echocardiogram showed a moderate-sized pericardial effusion without evidence of tamponade. Labs were remarkable for an c-reactive protein of 134.7 mg/L and erythrocyte sedimentation rate of 45 mm/hr. Remainder of workup evaluating for infectious or rheumatologic etiology was unremarkable.
Given otherwise negative workup, concomitant pleural and pericardial effusion were thought to be secondary to Dressler’s syndrome in the setting of pacemaker implantation. The patient was started on steroids and colchicine and on follow-up one month after completion of treatment, pleural and pericardial effusions had resolved.
Discussion: Post-cardiac injury syndrome (PCIS) is a spectrum of disease presentations that can range from Dressler’s pericarditis to pleuropericarditis. While the incidence is not accurately recorded, it has been reported in association with coronary artery bypass grafting, percutaneous intervention, ablation of arrhythmias, and pacemaker implantation. Patients with recent cardiac intervention (between 1 week to 3 months) who have 2 of the following 5 findings – fever without an alternative explanation, pericardial or pleuritic chest pain, pericardial or pleural rubs, pericardial effusion, and/or pleural effusion with elevated C-reactive protein – meet criteria for PCIS.
In studies of patients with PCIS, they commonly present with left sided, unilateral pleural effusions (83%). 97% of pleural fluid from patients with PCIS are exudative. Between 1975 and 2014, there have been 10 reported cases of PCIS after pacemaker placement. 7 of these cases improved with medical management, whereas 3 required surgical intervention.
Our patient presents similarly to prior documented cases of PCIS following pacemaker implantation – symptom onset was weeks from initial cardiac injury, and at that time had predominantly left sided exudative pleural effusion, and pericardial involvement.
Conclusions: This case emphasizes the importance of hospitalists recognizing PCIS as a possible complication of pacemaker implantation. Early diagnosis and medical management may decrease need for invasive procedures and decrease number and length of hospitalizations.