Case Presentation: A 75 year old male presented with 4 syncopal episodes occurring over the 3 days prior to admission. Each syncope lasted 2-3 minutes and followed a coughing fit. The patient had an aortic valve replacement for aortic stenosis 3 weeks prior. Transthoracic echocardiogram (TTE) 2 days post-surgery showed no pericardial effusion. At discharge, the patient had begun to develop a non-productive cough, which over the course of the following 2 weeks developed into coughing spells, accompanied by malaise. Patient denied fevers, chest pain, dyspnea and palpitations. Physical exam revealed a II/VI systolic murmur with no friction rub. Vitals were: T 98.4, BP 121/59, HR 79, RR 18. Repeat TTE demonstrated a moderate to large pericardial effusion and CT chest showed moderate bilateral pleural effusions. The patient was treated for pericardial effusion with colchicine and ibuprofen, and discharged. Subsequently, patient’s antibodies tested positive for B. Pertussis IgG/IgA, and he was contacted and started on a macrolide for a 5 day course.
Discussion: This case reminds us that the tendency to embrace the most probable diagnosis can stymie pursuit of a broader differential and ensnare clinicians in the cognitive trap of early closure. This patient demonstrated a classic presentation of Postpericartiotomy Syndrome (PPS). PPS is an inflammatory process that develops in 10-40% of patients who undergo surgery that involves the pericardium. Onset is within days to weeks following surgery. Diagnostic criteria are ≥ 2 of: new or worsening pericardial effusion, fever without an infectious source, pleuritic chest pain, pleural effusion and pericardial friction rub. Associated symptoms are non-specific, and include fatigue, malaise, cough, and syncope in the case of tamponade. Treatment consists of aspirin or NSAIDs, colchicine, and in refractory cases, steroids. PPS is differentiated from Dressler’s which presents similarly but occurs after a myocardial infarction.
Applying Occam’s razor, the initial approach focused on the most likely diagnosis given the proximity of presentation to the patient’s surgery. However, paroxysmal coughing fits coupled with post-tussive syncope, in the absence of recent cardiac surgery, would have compelled consideration of Pertussis. Pertussis, or whooping cough, is an acute respiratory tract infection that has recently increased in incidence, including among the elderly. Classic presentation follows 3 stages: (i) a catarrhal stage of 1-2 weeks characterized by malaise, rhinorrhea and a mild cough; (ii) a paroxysmal stage of severe coughing fits, associated with inspiratory whoop (primarily in infants) and post-tussive vomiting or fainting, lasting 2-8 weeks; and (iii), a convalescent stage of persistent but decreasing frequency of cough. Diagnostic criteria are a cough for at least 2 weeks with one classic sign of pertussis, confirmed by laboratory testing. Treatment with a macrolide for 5 days has not been demonstrated to improve symptoms, but does reduce transmission.
While, in this case, appropriate diagnostic tests were fortuitously sent, the management quickly narrowed to PPS. In retrospect, given the high infectivity of Pertussis, maintaining a broader differential and treating accordingly would have been more appropriate.
Conclusions: Pertussis and PPS are common diseases. Hospitalists should always consider recent surgery when developing a differential, but this case reminds us that other diseases may occur post-surgery, and a careful history remains paramount.
To cite this abstract:Heching M, Canepa C, Kapadia T, Verplanke B, Steinberg D. Pertussis and Postpericardiotomy Syndrome, a Coughing Matter. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 540. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/pertussis-and-postpericardiotomy-syndrome-a-coughing-matter/. Accessed July 16, 2019.