Cholesterol pericarditis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Cholesterol pericarditis is a rare disorder. It was first described by Alexander in 1919 [1] in a patient who had a pericardial effusion which resembled gold paint. The pathophysiology of cholesterol pericarditis is unclear. It has been associated with hypothyroidism, and may respond to therapy for hypothyroidism. In the absence of hypothyroidism, there are a variety of associated diseases, and it has been speculated that these result in reduced absorption of cholesterol by an inflamed pericardium.
Pathophysiology
The pathogenesis of cholesterol pericarditis is unclear.
Hypothyroidism is associated with effusions in several locations including the pleura, peritoneum and the pericardium. Hypothyroidism is also associated with hypercholesterolemia. It is therefore no surprise therefore thathypothyroidism may be a cause of the cholesterol accumulation. Consistent with the pathophysiologic role of hypothyroidism, the pericardial effusion in some of these patients does respond to treatment of the hypothyroidism. In Brawley's series [2], the average serum cholesterol was 293 mg/dl in the nine cases of hypothyroidism.
Using carbon labeled cholesterol, decreased resorption of cholesterol was documented in a patient with chronic pericarditis of unknown etiology.
Diagnosis
Symptoms
Patients may complain of non specific symptos such as fatigue, dyspnea, and chest pain. Depending upon the rate and extent of their presentations the patient may complain of dyspnea, orthopnea, or syncope, signs and symptoms consistent with tamponade.
Physical Examination
The findings on physical examination are those of a large pericardial effusion.
Neck: Elevated neck veins.
Heart: A diffuse apical impulse. Heart sounds are diminished.
Abdomen: Ascites may be present
Extremities: Edema
Electrocardiogram
The electrocardiogram generally shows low amplitude in the precordial leads and nonspecific T wave changes.
Chest x-ray
The chest film may show cardiomegaly.
Differential Diagnosis of Associated Conditions
The largest collection of cases reported on in the literature was by Brawley, who reported the following associations:
- Hypothyroidism (11 of 47 patients in a series by Brawley had associated hypothyroidism)
- Rheumatoid arthritis (5 of 47 patients in the Brawley series)
- Hypertension (3 of 47 patients in the Brawley series)
- Tuberculosis (3 of 47 patients in the Brawley series)
Less common causes:
- Atrial septal defect
- Mitral stenosis
- Sheehan's syndrome
- Bronchial carcinoma
- Idiopathic in 21 of the 47 patients in the Brawley series
Diagnosis
Examination of the pericardial fluid in cholesterol pericarditis shows cholesterol crystals, foam cells, macrophages and giant cells. The fluid in cholesterol pericarditis is clear, and classically is said to have a glittering "gold paint" appearance.
Treatment
Underlying treatment of hypothyroidism may aid in the resolution of the pericardial effusion. Otherwise, pericardial drainage and pericardiectomy is recommended. There is undocumented support for steroid installation into the pericardium.