Primary cardiac mesothelioma presenting with fulminant recurrent pericarditis: a case report

Our plain-English summary of Primary cardiac mesothelioma presenting with fulminant recurrent pericarditis: a case report, by S. Schwartzenberg, Y. Shapira, V. Rubachevski, et al (European Heart Journal. Case Reports, 2023).

The study

• Authors: S. Schwartzenberg, Y. Shapira, V. Rubachevski, R. Sharony
• Journal: European Heart Journal. Case Reports
• Published: 2023;7(3):ytad100
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Primary pericardial mesothelioma is an extremely rare disease. Prognosis is poor, with little effects of chemo- or radio-therapy. The majority of cases is diagnosed at autopsy.

Case Summary: A 22-year-old man, who presented with recurrent pericarditis and large pericardial effusion 2 months after a second BNT162b2 COVID-19 vaccine, underwent pericardiocentesis and pericardial window. Pathology specimen of pericardium revealed benign mesothelial inflammation, consistent with acute pericarditis. Four months later, he presented with a large pericardial mass manifesting in heart failure and underwent urgent pericardiectomy. A new pathology specimen immunostaining and fluorescence in situ hybridization analysis revealed pericardial mesothelioma. Despite intensive care, the patient died 3 weeks later.

Discussion: Primary pericardial mesothelial should be considered in the differential diagnosis of refractory recurrent pericarditis, even with prior biopsy-proven pericarditis or when a putative trigger (COVID-19 mRNA prior vaccination) is suspected, as was the case in this patient. Tumour diagnosis and identification consist of multimodal imaging and laboratory tests. A multidisciplinary, individualized care approach should be performed.

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.

In plain English

This case report described a 22-year-old man with no history of smoking or previous asbestos exposure. He developed chest pain and shortness of breath in March 2021, after his second Pfizer-BioNTech (BNT162b2) COVID-19 vaccine, and was diagnosed with acute pericarditis with fluid around the heart. Fluid was drained twice, and tissue taken during a pericardial window operation showed benign inflammation with benign mesothelial proliferation. The authors at first considered the vaccination a possible risk factor. Four months later he returned with chest pain and shortness of breath. CT showed a pericardial layer 4 cm thick, and surgery found a 3 cm inflamed layer wrapping the heart that could be only partly removed. He needed ECMO support, developed multiorgan failure, and died 3 weeks later. Tissue from the operation showed malignant pericardial mesothelioma, supported by a CDKN2A deletion in 70% of cells. Re-examination of the first specimen found no dysplasia or atypical changes. The authors interpreted this as pericarditis that transformed into mesothelioma within 4 months. They concluded that pericardial mesothelioma should be considered in refractory recurrent pericarditis, even after biopsy-proven pericarditis.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One previously healthy 22-year-old man, reported by authors from Rabin Medical Center, Israel; his illness ran from March to September 2021 according to the article's timeline
• Exposure: No history of smoking or previous asbestos exposure was reported. He had received a second BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine before the first episode.
• Main results:
  • Tissue from the first operation (pericardial window) showed benign acute and chronic inflammation with benign mesothelial proliferation
  • The authors initially considered the COVID-19 vaccination a putative risk factor for the pericarditis
  • Four months later, CT showed a large pericardial layer 4 cm thick
  • At surgery, the heart and great vessels were wrapped by a severely inflamed fibro-gelatinous layer 3 cm thick
  • Despite ECMO support and other intensive care, the patient died 3 weeks later
  • The later operative specimen stained positive for mesothelial markers
  • FISH analysis found CDKN2A homozygous deletion in 70% of the cells, which the authors said verified malignant mesothelioma
  • Re-examination of the first specimen found a positive BAP-1 stain (no BAP-1 loss). The authors took this as consistent with pericarditis that later transformed into mesothelioma.
  • The authors believed this was only the second reported case of pathologically confirmed pericarditis that transformed into mesothelioma
• The authors' conclusion: The authors concluded that primary pericardial mesothelioma should be considered in the differential diagnosis of refractory recurrent pericarditis, even with prior biopsy-proven pericarditis. They added that extensive pericardial malignancy can mimic pericardial effusion on cardiac imaging.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma, Pericardial Mesothelioma, Prognosis, Autopsy, Pericardial Effusion, Pericardiocentesis, Pericardial, Pathology.

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