Important Constrictive Pericarditis in a Patient with Schistosomiasis: A Case Report

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Introduction
Schistosomiasis mansoni (SM) is one of the most common causes of pulmonary hypertension and is often associated with the hepatosplenic form of the disease.However, constrictive pericarditis (CP) is not cited in the medical literature as a consequence of SM. 1,2 One single case report, published in 1979, associating CP with schistosomiasis, presented the etiologic agent of Schistosoma haematobium. 3he present study described a rare case of CP in a patient with chronic hepatosplenic SM, with a significant improvement in the parameters of ventricular filling and myocardial deformation after surgery, illustrating the importance of the echocardiogram in the detection of complications caused by this disease.

Case report
A 47-year-old, female patient, diagnosed with schistosomiasis 10 years ago, presented signs of right heart failure (jugular ingurgitation, hepatomegaly, edema of the lower limbs) and left heart failure (exhaustion with minimum/ maximum effort, hypotension).The precordium examination showed no abnormalities and upon auscultation of the heart, one could hear a third sound and a discrete systolic murmur on the left sternal border.
The preliminary echocardiogram showed a major biatrial dilation, signs of mild pulmonary hypertension (41 mmHg), major thickening of the pericardium with no stroke, and the interventricular septum with an altered movement, with a "septal bounce " pattern (Figure 1).The spectral Doppler showed a mitral flow with a left ventricular restrictive pattern, and the Tissue Doppler (TD) of the mitral ring with a septal-lateral inversion in an Annulus reversus pattern (Figure 2).The speed of left ventricle (LV) outflow was above 100 cm/s and the LV's longitudinal global strain (LGS) was discretely reduced (-14.7%),with an accentuated decrease DOI: https://doi.org/10.36660/abcimg.2023378i in the inferolateral and anterolateral walls (Figure 3).Taking these data into account, the CP diagnostic hypothesis was conducted, together with x-ray.A partial surgical pericardiectomy was recommended, revealing an important calcification and adherence of the pericardial layers; the material was sent to the pathological anatomy department (Figure 4).
Eight months after the surgery, there was a clear improvement in the systolic function and the LV filling pattern, diminishing the atrial volumes and increasing the speed of the e´ wave of the lateral ring in relation to the speed of the LV, which increased to -20.7% strain, with the disappearance of the alterations in the inferolateral and anterolateral walls (Figure 5).

Discussion
Chronic CP is associated with a wide range of possible causes.The disease develops in an insidious manner and, in many cases, the etiology remains undefined. 4The diagnosis of CP is based on symptoms and signs of heart failure due to the constriction of the pericardium associated with one or more imaging methods.Transthoracic echocardiography (TTE) is recommended in all patients suspected of CP. 5 Schistosomiasis, a tropical endemic parasitosis, can lead to pulmonary hypertension due to the occlusion of the pulmonary arterioles by the SM eggs.The myocardial and pericardial involvement of SM species is rare and can occur due to the accumulation of SM eggs, which induce a local granulomatous response. 6In the only case published in the medical literature, 3 the histopathological study of the pericardium showed a fibrous thickening with an increase in the connective tissue and identified the presence of Schistosoma haematobium eggs.In the present case, the anatomopathological study of pericardial fragments showed fibrous connective tissue, showing extensive dystrophic calcification, but no SM eggs were identified.Two possibilities can be suggested: the absence of eggs in the analyzed fragments and/or the disintegration of the eggs.In any case, the etiological possibility cannot be discarded, since there was no medical history or other concomitant disease that could be attributed as a cause of CP.The TTE identified various parameters of CP, which normalized in the exams performed about eight months after the excellent result of the surgical procedure (Figure 5).The analysis of the myocardial strain can aid in providing a more precise detection of the adherence of the pericardium to the myocardium along the free wall of the LV, aiding in the diagnosis of CP, as illustrated the present case.

Case Report
Castillo & Brindeiro Constrictive pericarditis and schistosomiasis

Figure 1 -
Figure 1 -Eco 2D 4C showing the dilation of the atriums and tricuspid regurgitation; B) Estimation of pulmonary systolic blood pressure using the continuous Doppler; C) Mode M "septal bounce" and pericardial thickening.PSAP: Pulmonary Systolic Arterial Pressure.

Figure 3 -
Figure 3 -Left: Colored Mode M; Speed of outflow with 220 cm/s (arrow photo); Right: LGS, 14.8% (arrow photo) with evident decrease in the inferolateral and anterolateral walls.

Figure 5 -
Figure 5 -Above (TD).Normalization of the speed of the lateral ring (lateral ring E´ wave > septal).Below (LGS).Normalization of the deformity in the inferolateral and anterolateral walls.

Figure 4 -
Figure 4 -Intense pericardial thickening observed in the chest X-ray (left) and during surgery (right)