Dressler's syndrome post-pacemaker insertion

A 75-year-old man underwent placement of a dual-chamber pacemaker for symptomatic sinus node disease in a tertiary referral centre. Three days after the procedure, he presented to the emergency department in the same hospital with right-sided, pleuritic chest pain and a diagnosis of pulmonary embolus was considered, although excluded by investigations which included spiral computed tomography and d-dimer. He was discharged, only to return the next day with increasing dyspnoea, and a transthoracic echo confirmed the clinical diagnosis of a significant pericardial effusion with early signs of tamponade physiology. In the operating room 700 ml of blood-stained fluid was aspirated and the patient's symptoms improved dramatically. Chest X-ray and pacemaker interrogation did not necessitate re-positioning of the pacemaker leads. One month later he returned to his local hospital complaining of increasing dyspnoea and a chest X-ray (Figure 1) demonstrated a large right pleural effusion and a smaller effusion on the left. There was a moderate pericardial effusion without tamponade (Figure 2). The larger of the pleural effusions was aspirated with improvement in the patient's symptoms, but recurrence of the fluid, persistent symptoms, a low grade fever and a high erythrocyte sedimentation rate, led to consideration of Dressler's syndrome. The patient was commenced on prednisolone 60 mg daily and both his symptoms and the pleural effusion resolved.