A pilgrim seeking diagnosis

We present the case of an unusual presentation of Dressler’s syndrome and the important role of new imaging techniques in its diagnosis. A 42-year-old man was admitted with progressive dyspnoea and pleuritic chest pain during the last two months. Physical examination showed signs of hemodynamic instability (BP 75/40, HR 120 bpm). X-Ray showed cardiomegaly and electrocardiogram was suggestive of chronic anterior myocardial infarction. Transthoracic echocardiography showed pericardial effusion with signs of hemodynamic compromise. Emergent cardiac surgery was performed with suspicion of cardiac rupture. Only fibrinous material and serous fluid was found. 72 hours later he required reoperation because of recurrence of cardiac tamponade. Pleuropericardial window was made. Anti-inflammatory treatment was initiated. At discharge a magnetic resonance imaging study was performed. Diffuse pericardial inflammation consistent with a diagnosis of Dressler’s syndrome (DS) was demonstrated in T2- weighted black-blood and late enhancement sequences. One month later neither pleural nor pericardial effusion had recurred. Postinfarction pericardial effusions are common and magnetic resonance imaging has proven useful in determining its aetiology.