Cardiac complications after mediastinal radiation for Hodgkin lymphoma include coronary artery disease, valvular disease, and acute and chronic pericardial disease [1]. The late appearance of chronic pericardial disease has been reported, but no more than 10 years after radiation [2, 3]. We report two cases of delayed chronic pericardial disease occurring 20 and 23 years, respectively, after treatment of Hodgkin lymphoma.

Case 1: A 45-year-old woman with Hodgkin lymphoma who had been treated with mediastinal radiation 23 years previously presented with exertional dyspnea that had lasted 2 months, leg edema, and a transudative pleural effusion. Physical examination showed a blood pressure of 170/80 mm Hg, a pulse of 100 beats/min, and respirations of 20 breaths/min. Jugular veins were distended to the mandible, with prominent x and y descents. The patient's lungs were clear. A 2/6 holosystolic murmur was noted at the apex, a 1/6 early diastolic murmur was detected at the base, and a fourth heart sound was heard. The abdomen was distended with a fluid wave, and the ankles showed pitting edema. An echocardiogram showed preserved systolic left ventricular function, a thickened aortic valve, mild aortic and mitral regurgitation, and a small pericardial effusion. Ventricular hemodynamics showed near equilibration of end diastolic pressures and a late diastolic plateau consistent with pericardial constriction (Figure 1, top). The patient's mean right atrial pressure was 18 mm Hg, with prominent x and y descents. Trace aortic and mitral regurgitation was noted, with an ejection fraction of 74%. The patient had partial epicardiectomy and had improved when discharged after 1 week. Pathologic examination of the restricted epicardium showed no evidence of cancer or infectious agents.

View larger version (60K): [in this window] [in a new window]   Figure 1. Top. For case 1, intraventricular hemodynamic tracings with simultaneous electrocardiographic (ECG) tracings. Shown are an elevated right ventricular (RV) systolic pressure and characteristic diastolic dip and plateau suggesting constrictive physiology. The left ventricular (LV) systolic pressure is 140 mm Hg (not shown). Bottom. For case 2, photoµgraph of visceral pericardium (obtained at postmortem examination) showing extensive fibrosis and thickening (epicardial surface, top right). The pericardium is infiltrated by chronic inflammatory cells and contains dilated capillaries. The underlying myocardium (lower left) shows patchy areas of fibrosis.

Case 2: A 36-year-old woman with a history of Hodgkin lymphoma had been treated with mediastinal radiation 20 years previously. While hospitalized for breast reconstruction surgery, the patient developed dyspnea and a transudative right pleural effusion. Nine years before hospital admission, the patient had had a right modified radical mastectomy for breast carcinoma. One year later, a local skin recurrence had been treated with cyclophosphamide, doxorubicin hydrochloride, vincristine, prednisone, and local radiotherapy. Medications included furosemide and subcutaneous heparin. Physical examination showed the blood pressure to be 104/70 mm Hg, the pulse to be 100 beats/min, and respirations to be 20 breaths/min. A pulsus paradoxus of 12 mm Hg, marked jugular vein distention, and a soft pericardial knock were detected. Pitted lower-extremity edema extended to the midcalf. An echocardiogram showed a large pericardial effusion, no evidence of tamponade, and normal systolic function. While the patient awaited cardiac catheterization, dyspnea and severe hypotension developed. Emergent left thoracotomy and pericardial drainage were done. Blood pressure transiently improved after 400 mL of pericardial fluid was removed, but hypotension recurred in the operating room and the patient died. Postmortem examination showed a large pulmonary embolism and extensive visceral pericardial and subepicardial fibrosis (Figure 1, bottom). Ascites and hepatic congestion were noted, but metastatic breast carcinoma was not.

These two cases of effusive-constrictive pericarditis occurred more than 20 years after mediastinal radiation for Hodgkin lymphoma, and they underscore the range of complications for such treatment, including valvular insufficiency (case 1) and second cancer (case 2) [4, 5]. This side effect is important because other patients treated when cardiac shielding was not used could still develop this complication.

Gregory C. Kane, MD

Richard N. Edie, MD

John D. Mannion, MD

Jefferson Medical College

Philadelphia, PA 19107