Can multiple myeloma cause constrictive pericarditis?

Can Multiple Myeloma Cause Constrictive Pericarditis?

Multiple myeloma can cause pericardial involvement, but it typically presents as pericardial effusion with tamponade rather than constrictive pericarditis, and when pericardial disease occurs, it represents a rare and late-stage complication with a poor prognosis.

Mechanism of Pericardial Involvement in Multiple Myeloma

Multiple myeloma affects the pericardium through several distinct pathways:

• Direct plasma cell infiltration of the pericardium is the most specific mechanism, though rare 1, 2
• Amyloid deposition from light chain disease can involve both the myocardium and pericardium 1, 3
• Secondary complications including infections, bleeding diatheses, and treatment-related effects 1, 4

Clinical Presentation Pattern

The typical pericardial manifestation in multiple myeloma differs from classic constrictive pericarditis:

• Pericardial effusion with tamponade is the predominant presentation, not constriction 1, 2, 3
• Patients present with progressive dyspnea and signs of cardiac tamponade requiring urgent pericardiocentesis 1, 2
• Restrictive cardiomyopathy from amyloid infiltration of the myocardium is more common than constrictive pericarditis 3
• When pericardial involvement occurs, it usually represents late or terminal stage disease 1, 2

Diagnostic Considerations

When evaluating potential pericardial disease in multiple myeloma patients:

• Cytologic examination of pericardial fluid can demonstrate plasma cell infiltration 1, 2
• Immunocytochemical assay of pericardial fluid helps confirm myelomatous involvement 2
• Pericardial biopsy via pericardial window provides definitive tissue diagnosis 1
• Look for laboratory clues including pancytopenia, hypogammaglobulinemia, and proteinuria that suggest underlying myeloma 2

Constrictive Pericarditis Risk in Context

According to ESC guidelines, neoplastic pericardial diseases carry an intermediate risk (2-5%) of progression to constrictive pericarditis 5. However, this risk applies broadly to malignant pericardial involvement and does not specifically address multiple myeloma, where:

• Effusive disease predominates over constrictive physiology in reported cases 1, 2, 3
• The clinical course is typically rapidly progressive and fatal before constriction develops 1
• One case report documented effusive-constrictive pericarditis in a patient with multiple myeloma history, but this occurred post-cardiac surgery rather than from direct myelomatous involvement 6

Prognostic Implications

The prognosis for myeloma patients with pericardial involvement is grave:

• All reported cases with proven myelomatous pericardial infiltration died of progressive disease despite chemotherapy and supportive measures 1
• Optimal treatment has not been established for malignant pericardial involvement by myeloma cells 1, 3
• Intrapericardial bleomycin has been attempted but with limited success 3

Clinical Pitfall

Do not assume pericardial disease in a multiple myeloma patient is automatically myelomatous—consider alternative etiologies including:

• Infectious pericarditis (bacterial, viral including RSV in transplant patients) 4, 6
• Treatment-related pericarditis (post-transplant, post-radiation if applicable) 4, 6
• Uremic pericarditis from renal involvement 5
• Amyloid-related disease versus direct plasma cell infiltration 1, 3