Prepared by Sagar Nigwekar, MD, Resident, Department of Medicine, and Ming Chow, MD, Intensive Care Attending Physician, Rochester General Hospital, Rochester, NY

An 80-year-old Ukrainian man presents with 1 week?s history of palpitations, low-grade fevers, and generalized weakness. He denies any upper respiratory symptoms, chest pain, or shortness of breath. Physical examination is remarkable only for decreased breath sounds and distant heart sounds, with a pericardial friction rub. There is no pulsus paradoxus or Kussmaul?s sign, and an electrocardiogram shows normal sinus rhythm with normal voltage. A chest x-ray shows cardiomegaly with a small, right-sided pleural effusion. Computed tomography (CT) scan of the chest is shown in Figure 1. Results of a pericardiocentesis were: protein, 4 g/dL; glucose, 84 mg/dL; red blood cell count, 10.0 x 10⁶/?L; white blood cell count, 1.9 x 10³/?L, with predominance of lymphocytes. Pericardial biopsy findings are shown in Figure 2.

What?s Your Diagnosis?

Primary pericardial mesothelioma

Sarcoid pericarditis

Tuberculous (TB) pericarditis

Metastatic pericardial effusion