Description

A 70 year old woman presented with increasing shortness of breath. Examination was suggestive of a
chest infection and she was treated with cefuroxime and erythromycin. The liver function tests (LFTs) were abnormal – alkaline phosphatase (ALP) 257 (normal<120), alanine transaminase (ALT) 40 (normal<40), bilirubin 23 (normal <17). Liver ultrasound showed prominent hepatic veins and inferior vena cava; a pleural effusion and splenomegaly. The inflammatory markers were markedly raised with an erythrocyte sedimentation rate (ESR) of 99 mm in the first hour and a C-reactive protein (CRP) of 252 (normal<7). An echocardiogram showed a rapidly enlarging pericardial effusion. 1500mls of serosanguinous fluid was removed and the cause extensively investigated (table 1). The patient remained breathless with a high jugular venous pressure and had the echocardiographic signs of constrictive pericarditis. Prednisolone 30mg orally was commenced. There was a rapid improvement clinically (the jugular venous pressure reverted to normal) and in the inflammatory markers. At outpatient review two weeks after discharge she was well taking 20mg of prednisolone daily. The ESR had fallen to 12 and the prednisolone was discontinued over the next few weeks.