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A case of progressive breathlessness

BMJ 2010; 341 doi: (Published 22 September 2010) Cite this as: BMJ 2010;341:c4655
  1. Emma Holden, specialist respiratory registrar1,
  2. Harpreet Ranu, specialist respiratory registrar1,
  3. Brendan P Madden, professor of cardiovascular medicine1
  1. 1St George’s Hospital, Tooting, London, UK
  1. Correspondence to: B P Madden, St George’s Hospital, Tooting, London, SW17 0QT, UK Brendan.Madden{at}

A 57 year old white man was seen in the outpatient clinic with a four month history of breathlessness on exertion, particularly when climbing the stairs. The breathlessness had started after a protracted episode of fever, weight loss, and breathlessness. His only medical history was pleurisy as a child, which had resolved after a routine course of antibiotics. He had no long term sequelae from this disease. He was a lifetime resident of the United Kingdom.

On examination the patient did not have a fever or any palpable lymphadenopathy. His heart rate was 76 bpm in normal sinus rhythm, jugular venous pressure (venous pulse) raised at 11 cm above the right atrium, and blood pressure 122/76 mm Hg, and his heart sounds were normal. His chest was clear but examination of his abdomen showed hepatomegaly. He had no pedal oedema. Oxygen saturations were 99% on room air. He did not desaturate after exercising up and down stairs; however, he did become tachycardic with a heart rate of 140 bpm.

Computed tomography pulmonary angiogram showed no evidence of pulmonary emboli; however, pericardial thickening was noted. An echocardiogram showed inspiratory decrease of transmitral early diastolic flow, dilated inferior vena cava without inspiratory collapse, and a bright pericardium. Cardiac catheterisation showed minor coronary artery disease, with equal diastolic pressures in the left and right atria and ventricles. The patient underwent cardiac magnetic resonance imaging (figs 1 and 2).

Figure 1

Figure 2

Bloods tests showed a bilirubin concentration of 54 μm/l, alkaline phosphatase of 556 U/l, γ glutamyltransferase of 864 U/l, and alanine transaminase of 43 U/l. A tuberculin skin test was performed (2 tuberculin units in 0.1 ml solution for injection), and the palpable raised area measured 22 mm. An interferon gamma test was not performed because the test …

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