Uremia-associated fibrinous pericarditis

A 53-year-old man with hemodialysis-dependent end-stage renal disease secondary to HIV-associated nephropathy collapsed in public and was declared dead. The patient had been discharged 1 week prior after a 2-week admission for osteomyelitis and an epidermal phlegmon involving lumbar vertebrae with Staphylococcus aureus bacteremia. During that admission, an echocardiogram showed decreased ejection fraction and left ventricular hypertrophy, but notably no pericardial effusion. Pertinent laboratory testing at that time and before inpatient hemodialysis showed serum creatinine of 7.3 mg/dl, blood urea nitrogen of 70 mg/dl, and HIV RNA <20 copies/ml. The patient was discharged; however, he did not present for scheduled hemodialysis over the week before death. An autopsy was performed and revealed a 1250 ml pericardial serosanguineous effusion, with ragged/fibrinous material overlying the pericardial surfaces as evident grossly and microscopically (Figure 1 and Supplementary Figure S1). The pericardium was devoid of involvement by neoplasm or infectious organisms, and there was notably no evidence of acute myocardial infarction. The absence of fibrosis/scarring of the epicardium supported the acute nature and evolution of the fibrinous pericarditis as well as arguing against a history of preceding contributory episodes. The patient did not have prior iatrogenic intervention or history of trauma involving the pericardium or thorax. Further, the patient lacked a history of autoimmune disease, with a workup 3 years prior revealing negative antinuclear antibody and anti–double stranded DNA serology. A limited blood sample collected during resuscitation showed creatinine of 17.5 mg/dl, blood urea nitrogen of 107 mg/dl, and glucose of 167 mg/dl. The patient did not exhibit edema or significant pleural or peritoneal effusions. The development of an acute fibrinous pericarditis and the volume of pericardial effusion would have an imparted tamponade effect on the heart and most significantly contributed to the patient’s terminal demise. In the setting of end-stage renal disease, missing of vital hemodialysis, and the exclusion of other etiologies, the fibrinous pericarditis and pericardial effusion were considered uremia-associated.