A cheesy exudate: a case report on management of pericardial disease through multimodal cardiac imaging.

Background: Cholesterol pericardial effusion is a rare diagnosis and typically not associated with the development of pericardial constriction. However, covariate factors, such as Rheumatoid arthritis, myxoedema, and comorbid disease requiring anticoagulation, can predispose to developing dense adhesions that ultimately can cause pericardial constriction and constrictive physiology. This can develop without preceding symptoms but ultimately may declare itself with a variety of clinical presentations including syncope. Case summary: We present a patient with a pericardial mass incidentally identified during hospital evaluation after presentation with syncope. Initial suspicion based on computed tomographic angiography (CTA) appearance was of a pericardial cyst. Additional multimodal imaging consisting of transthoracic echocardiogram (TTE) and magnetic resonance imaging (MRI) supported evidence of a right ventricular-compressive effusion with constrictive physiology, findings more suggestive of a loculated pericardial effusion than a pericardial cyst without evidence of pericardial inflammation. Although transoesophageal echocardiography (TEE) guided pericardiocentesis was technically successful, it failed to produce clinical or haemodynamic improvement of the pericardial constriction. Partial local pericardiectomy and cruciate incision of the anterior aspect of the rind was essential in relieving the constrictive process. Pathologic analysis of resected pericardium demonstrated cholesterol granuloma. We discussed the role of multimodal imaging in disease classification, as well as coexisting conditions such as rheumatoid arthritis and anticoagulation for pulmonary embolism that contributed to this case's unique presentation and timeline. Discussion: This case underscores the critical role of a multimodality imaging strategy in pericardial disease-particularly in managing rare cholesterol loculated effusions-and highlights how coexisting conditions can shape disease progression and treatment timing.