A 55-year-old woman who is status-post mantle field radiation of the mediastinum for Hodgkin's Lymphoma develops the gradual onset of dyspnea on exertion. Pulsus paradoxus is not present and cardiac markers such as troponin and creatine kinase are not elevated. Pulmonary function tests reveal a restrictive pattern. A video of her jugular venous pulse is shown. Which of the following is the most likely explanation for the clinical findings?
- Aortic regurgitation
- Constrictive pericarditis
- Hypertrophic cardiomyopathy
- Myocardial infarction
- Superior vena cava syndrome
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Answer: B) Constrictive pericarditis
This patient's Hodgkin's lymphoma was treated with mediastinal radiation resulting in fibrosis of the lungs and pericardium. The pericardium contracted causing a constrictive pericarditis and impaired filling of the heart producing a classic physical exam finding Kussmaul's sign. The video shows a dramatic example of Kussmaul's sign which is distension of the jugular veins and elevated jugular venous pressure during inspiration.
Kussmaul's sign can be seen in:
- Constrictive pericarditis
- Restrictive cardiomyopathy
- Right ventricular infarction
- Right ventricular failure
- Tricuspid stenosis
VideoSource: NEJMvideos
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