Clinical and historical features of emergency department patients with pericardial effusions

BACKGROUND: Diagnosing pericardial effusion is critical for optimal patient care. Typically, clinicians use physical examination ? ndings and historical features suggesting pericardial effusion to determine which patients require echocardiography. The diagnostic characteristics of these tools are not well described. The objective of this study is to determine the prevalence of historical features and sensitivity of clinical signs to inform clinicians when to proceed with echocardiogram.METHODS: A retrospective review of point-of-care echocardiograms performed over a two and a half year period in two emergency departments were reviewed for the presence of a pericardial effusion. Patient charts were reviewed and abstracted for presenting symptoms, historical features and clinical findings. The prevalence of presenting symptoms and historical features and the sensitivity of classic physical examination ? ndings associated with pericardial effusion and tamponade were determined.RESULTS: One hundred and fifty-three patients with pericardial effusion were identified. Of these patients, the most common presenting complaint was chest pain and shortness of breath. Patients had no historical features that would suggest pericardial effusion in 37.5% of cases. None of the patients with pericardial effusion or pericardial tamponade had all of the elements of Beck's triad. The sensitivity of Beck's triad was found to be 0(0%–19.4%). The sensitivity for one ? nding of Beck's triad to diagnose pericardial tamponade was 50%(28.0%–72.0%).CONCLUSION: History and physical examination findings perform poorly as tests for the diagnosis of pericardial effusion or pericardial tamponade. Clinicians must liberally evaluate patients suspected of having a pericardial effusion with echocardiography.

Subxyphoid Pericardial Drainage for Tuberculous Pericardial Effusion in Antananarivo

Introduction: Tuberculosis is the leading cause of pericardial effusion in sub-Saharan African countries. The aim of this study was to describe the diagnosis and the surgical management of tuberculous pericardial effusion in low-income country. Methods: This was a retrospective and descriptive study performed at Vascular Surgery Unit for 10 years-period (from January 2012 to December 2021), including all cases of drainage of pericardial effusion due to tuberculosis. Results: Sixty-seven cases were recorded, including 38 males (56.71%) and 29 women (43.28%). The average age was 35.47 years old. Patients lived in urban areas in 67.16% of cases. Thirteen patients (13.43%) had a previous history of pulmonary tuberculosis. The most common risk factors for tuberculosis infection were malnourishment (80.59%), indoor air pollution (77.61%) and close contact with tuberculosis patient (40.29%). The commonest symptom were dyspnea, (95.52%), chest pain (89.55%), fever (67.16%), tachycardia (95.52%) and cough (80.59%). Twenty-seven patients (39.02%) presented clinical signs of cardiac tamponade. Electrocardiogram showed sinus tachycardia (97.53%) with microvoltage (39.02%). Chest-X-ray showed cardiomegaly (100%) and pleural effusion (56.71%). Echocardiography showed moderate (43.28%) and large (56.71%) pericardial effusion. All patients underwent subxiphoid pericardial drainage. Mycobacterium tuberculosis detection via GeneXpert test of pericardial effusion were positive in 38.80% of patients. Pericardial biopsies confirmed the diagnosis of tuberculosis in 41.79%. The mortality rate was 8.95%. Conclusion: Subxiphoid pericardial drainage reduced thr risk of cardiac tamponade in patients with massive pericardial effusion. Histopathology of pericardial biopsies made a definitive diagnosis for tuberculosis.

Pericardiocentesis with cisplatin for malignant pericardial effusion and tamponade

AIM:To evaluate the role and outcome of pericardiocentesis with intrapericardial cisplatin instillation for malignant pericardial effusion resulting from esophageal cancer. METHODS:We retrospectively studied 7 patients who underwent pericardiocentesis with intrapericardial cisplatin instillation for malignant pericardial effusion resulting from esophageal cancer.After pericardiocentesis,we performed catheterization of the pericardial space under ultrasonogram guidance.Malignant etiology of the pericardial fluid was confirmed by cytological examination.Subsequently,cisplatin(10 mg in 20 mL normal saline) was instilled into the pericardial space. RESULTS:The mean total volume of the aspirated effusion fluid was 782±264 mL(range,400-1200 mL) . The drainage catheter was successfully removed in all patients,and the mean duration of pericardial drainagewas 7.7±2.7 d(range,5-13 d) .No fluid reaccumulation was observed.Mean survival time was 120±71 d(range,68-268 d) . CONCLUSION:Pericardiocentesis along with catheter drainage appears to be a safe and effective for pericardial malignant effusion and tamponade,and cisplatin instillation prevents recurrence.

Correct diagnosis and successful treatment for pericardial effusion due to toothpick injury: A case report and literature review

We reported a 55-year-old man who suffered from chest pain and dyspnea on exertion for two weeks associated with night sweating, general malaise, poor appetite, and body weight loss. Physical examination revealed friction rub with distant heart sound, bilateral clear breathing sound, no abdomen tenderness, and normal bowel sound. Subsequent chest X-ray revealed cardiomegaly and cardiac echo showed massive pericardial and pleural effusion with normal left ventricular function. Constrictive pericarditis was diagnosed based on clinical information. Tuberculosis (TB), malignancy, autoimmune disease, infection, hypothyroidism, and idiopathic could be the causes but excluded by further study. High-resolution lung CT scan after reconstruction revealed a moderate amount pericardial effusion with possible superimposed infection. Thickness of pericardium and left lobe liver abscess were found. A straight tubular structure about 6 cm in length transverses the lateral segment of liver to pericardial space and unknown foreign body was suspected. Laparotomy was performed, 6.5 cm toothpick was found through the liver into pericardium. Post-operative course was uneventful and he discharged one week later. The patient could not remember swallowing the toothpick before. He had no chest pain and dyspnea on exertion during a 6-mo follow-up period.

Clinical observation on pericardial effusion in patients with lung cancer treated by intrapericardial catheterization and infusion of highly agglutinative staphylococcin and cisplatin

Objective: To evaluate the therapeutic efficacy of injecting highly agglutinative staphylococcin (HASL) and cisplatin into pericardial cavity of lung cancer patients with pericardial effusion. Methods: 81 patients were randomized into two groups: 45 in the experimental group (HASL and Cisplatin) and 36 in the control group (Cisplatin). At first pericardial effusion was drained out from a intrapericardial catheter and then different drugs were infused, respectively. 24 h after perfusion the draining continued again until drainage quantity was less than 30 mL every day. The draining lasted 10–15 days. Results: The response rate was 91.1% for the experimental group and 80.6% for the control group. There was no significant difference between the two groups (P>0.05). The complete remission was 77.8% for the experimental group and 52.8% for the control group, which was statistically significant difference (P<0.05). The adverse effects were myelosuppression and nausea and vomiting, which were 35.6% and 40.0% in the experimental group and 72.2% and 66.7% in the control group, respectively (P<0.01, P<0.05). Conclusion: Inject- ing HASL and cisplatin into pericardial cavity may be a better way to control pericardial effusion of lung cancer.

Pulmonary hypertension concurrent with pericardial effusion and superior vena cava syndrome: who is the initiator?

The diagnosis of pulmonary hypertension(PH) should be made by combining clinical manifestations and echocardiographic probability.[1] Following the confirmation of PH, the classification should begin with the more common groups [group 2(PH due to left heart disease) and group 3(PH due to lung diseases and/or hypoxia)], then group 4(chronic thromboembolic PH and other pulmonary artery obstructions) and finally group 1(pulmonary arterial hypertension) and group 5(PH with unclear and/or multifactorial mechanisms).[1] In this case, we demonstrate a rare scenario of obstruction-caused group 4 PH.

Prenatal diagnosis of cor triatriatum sinister associated with early pericardial effusion:A case report

BACKGROUND Cor triatriatum sinistrum or cor triatriatum sinister is a rare congenital heart disease that accounts for approximately 0.1%of all cardiac abnormalities.It is defined as the presence of an anomalous septum that divides the left atrium into two cavities,and in most cases,it can be asymptomatic or less frequently very severe.CASE SUMMARY A 37-year-old pregnant woman visited our hospital.In the first trimester scan,we detected signs of fluid in the pericardium(pericardial effusion)that reached the atriums.In the third trimester,an anomalous septum in the left atrium suspicious of cor triatriatum sinister was detected.Expectant management was decided,the pregnancy evolved normally and resulted in uncomplicated delivery of a healthy child.The findings in the prenatal scan were confirmed by echocardiography and the diagnosis of cor triatriatum sinister was confirmed.The newborn was asymptomatic at all times.CONCLUSION We show expectant management of cor triatriatum sinister and suggest an association between this entity and early pericardial effusion.

Hemorrhagic pericardial effusion following treatment with infliximab:A case report and literature review

BACKGROUND Infliximab(IFX)is an anti-tumor necrosis factor alpha(TNF-α)agent that is widely used for the management of a variety of autoimmune and inflammatory diseases,including Crohn's disease(CD).As a result of its increasing administration,new complications have emerged.Hemorrhagic pericardial effusion,secondary to IFX therapy,is a rare but life-threatening complication.CASE SUMMARY A 27-year-old man was diagnosed with CD(Montreal A2L3B1)6 years prior.After failing to respond to mesalazine and methylprednisolone,he took the first dose of IFX 300 mg based on his weight(60 kg,dose 5 mg/kg)on December 3,2018.He responded well to this therapy.However,on January 21,2019,1 wk after the third injection,he suddenly developed dyspnea,fever,and worsening weakness and was admitted to our hospital.On admission,computed tomography scan of the chest revealed a large pericardial effusion and a small rightside pleural effusion.An echocardiogram showed a large pericardial effusion and normal left ventricular function.Then successful ultrasound-guided pericardiocentesis was performed and 600 mL hemorrhagic fluid was drained.There was no evidence of infection and the concentrations of TNF-α,IFX,and anti-IFX antibody were 7.09 pg/mL(reference range<8.1 pg/mL),<0.4μg/mL(>1.0μg/mL),and 373 ng/mL(<30 ng/mL),respectively.As the IFX instruction manual for injection does mention pericardial effusion as a rare adverse reaction(≥1/10000,<1/1000),so we discontinued the IFX.Monitoring of the patient’s echocardiogram for 2 mo without IFX therapy showed no recurrence of hemorrhagic pericardial effusion.Follow-up visits and examinations every 3 to 6 mo until April 2021 showed no recurrence of CD or pericardial effusion.CONCLUSION This is a case of hemorrhagic pericardial effusion following treatment with IFX.It is a rare but life-threatening complication of IFX.Early recognition helps prevent the occurrence of hemorrhagic pericardial effusion and minimize the impact on the natural evolution of the disease.

Pericardial effusion with tamponade – an uncommon presentation leading to the diagnosis of eosinophilic granulomatosis polyangiitis: A case report

BACKGROUND Eosinophilic granulomatosis polyangiitis(EGPA)is a small vessel necrotizing vasculitis that commonly presents as peripheral eosinophilia and asthma;however,it can rarely manifest with cardiac involvement such as pericarditis and cardiac tamponade.Isolated pericardial tamponade presenting as the initial symptom of EGPA is exceedingly rare.Early diagnosis and appropriate treatment are crucial to prevent life-threatening outcomes.CASE SUMMARY 52-year-old woman with no past medical history presented with progressive dyspnea and dry cough.On physical exam she had a pericardial friction rub and bilateral rales.Vital signs were notable for tachycardia at 119 beats per minute and hypoxia with 89%oxygen saturation.On laboratory exam,she had 45%peripheral eosinophilia,troponin elevation of 1.1 ng/mL and N-terminal prohormone of brain natriuretic peptide of 2101 pg/mL.TTE confirmed a large pericardial effusion and tamponade physiology.She underwent urgent pericardial window procedure.Pericardial and lung biopsy demonstrated eosinophilic infiltration.Based on the American College of Radiology guidelines,the patient was diagnosed with EGPA which manifested in its rare form of cardiac tamponade.She was treated with steroid taper and mepolizumab.CONCLUSION This case highlights that when isolated pericardial involvement occurs in EGPA,diagnosis is recognized by performing pericardial biopsy demonstrating histopathologic evidence of eosinophilic infiltration.

Fruquintinib beneficial in elderly patient with neoplastic pericardial effusion from rectal cancer:A case report

BACKGROUND Neoplastic pericardial effusion(NPE)is a rare consequence of rectal cancer and carries a poor prognosis.Optimal management has yet to be determined.Fruquintinib is an oral anti-vascular endothelial growth factor receptor tyrosine kinase inhibitor approved by the China Food and Drug Administration in September 2018 as third-line treatment of metastatic colorectal cancer.CASE SUMMARY Herein,we report an elderly patient with NPE from rectal cancer who responded to the use of fruquintinib.In March 2015,a 65-year-old Chinese woman diagnosed with KRAS-mutated adenocarcinoma of the rectum was subjected to proctectomy,adjuvant concurrent chemoradiotherapy,and adjuvant chemotherapy.By October 2018,a mediastinal mass was detected via computed tomography.The growth had invaded parietal pericardium and left hilum,displaying features of rectal adenocarcinoma in a bronchial biopsy.FOLFIRI and FOLFOX chemotherapeutic regimens were administered as first-and second-line treatments.After two cycles of second-line agents,a sizeable pericardial effusion resulting in tamponade was drained by pericardial puncture.Fluid cytology showed cells consistent with rectal adenocarcinoma.Single-agent fruquintinib was initiated on January 3,2019,as a third-line therapeutic.Ten cycles were delivered before the NPE recurred and other lesions progressed.The recurrence-free interval for NPE was 9.2 mo,attesting to the efficacy of fruquintinib.Ultimately,the patient entered a palliative care unit for best supportive care.CONCLUSION Fruquintinib may confer good survival benefit in elderly patients with NPEs due to rectal cancer.

Controlling malignant pericardial effusion by intrapericardial administration of recombinant mutant human tumor necrosis factor in patients with carcinoma

Objective: To evaluate the therapeutic efficacy of injecting recombinant mutant human tumor necrosis factor (rmhTNF) into pericardial cavity of carcinoma patients with malignant pericardial effusion. Methods: In 20 cases of malignant pericardial effusion, the intrapericardial catheter was inserted into pericardial cavity, and then rmhTNF of 1.5 × 107 U was infused. The infusion was repeated every 5-7 days with the total 4-6 times. If the effusion disappeared, rmhTNF was then used 2 more times and then the intrapericardial catheter was pulled out. Results: Of 20 patients, 14 were complete response (CR), 4 were partial response (PR) and 2 no change (NC). The disappearance of effusion in 6 cases lasted for more than 6 months. Conclusion: Injecting rmhTNF into pericardial cavity may be a better way to control malignant pericardial effusion and has mild side effects.

Massive Pericardial Effusion as the First Manifestation of Hypothyroidism in a Male Patient

This article intends to report a rare case of massive pericardial effusion as the first manifestation of hypothyroidism. A 45-year-old male patient, accompanied by a cardiology department, suddenly started to present signs of dyspnea and tiredness. He was submitted to an echocardiogram and diagnosed with dilated cardiomyopathy associated with a moderate pericardial effusion and low ejection of fraction. The laboratory tests showed elevated TSH levels （13.20 mIU/L）, what leads to the hypothyroidism diagnose and enable to start the treatment with levothyroxine. The patient has not followed correctly the treatment, reason why he has not showed any improves. He was admitted in the hospital to cardiology monitoring and the chest radiography confirmed an intense pericardial effusion. Then, the patient was submitted to the pericardiocentesis procedure, which was capable of remove the pericardial fluid for laboratory analysis and fragment of the pericardial sac for neoplastic cell research. After the hospital discharge, he was maintained in outpatient follow-up, when showed an important improvement in the clinical state.

A Case Report of Hypothyroidism and Pericardial Effusion

The pericardial sac is made of two layers: the visceral and parietal pericardium. Located between these two layers, the pericardial cavity is found. It contains around 15 to 50 mL of a liquid secreted by mesothelial cells. Pericardial effusion is described as the accumulation of liquid within the pericardial cavity, exceeding the previous mentioned quantity. It has multiple causes, such as malignancy, infectious origins, inflammation, and others, such as hypothyroidism. One of the multiple clinical manifestations associated with hypothyroidism is pericardial effusion. It is related to the severity and duration of the disease, being more frequent in congenital hypothyroidism or cases of a long history of hypothyroidism, as well as clinical hypothyroidism. It can present a clinical challenge mainly due to the discordance between the total volume of the effusion and the clinical symptoms shown by the patient. The main objective of this work is to present a case of a forty-two-year-old male with hypothyroidism-associated pericardial effusion which resolved satisfactorily with hormone replacement therapy.

TEMPORAL TRENDS IN ETIOLOGY AND IN-HOSPITAL OUTCOME IN CHINESE PATIENTS WITH PERICARDIAL EFFUSION:10-YEAR EXPERIENCE OF A SINGLE CENTER

Objective To evaluate the evolution of etiology, clinical characteristics, and in-hospital outcomes of pericardial effusions in the recent decade. Methods All patients with a diagnosis of pericardial effusion during hospitalization were recruited from the Hospital Inpatient System between January 1996 and December 2005. Demographic and clinical characteristics, laboratory measurements, echocardiographic and treatment features, and in-hospital outcomes were retrospectively reviewed by using a standardized data collection form. Results One hundred and fifry-three consecutive patients were recruited. Mild, moderate and large pericardial effusion occurred in 61 （40%）, 52 （34%） and 40 （26%） patients, respectively. The most frequent etiologic diagnoses were tuberculous pericarditis （ n = 50, 33% ） , malignancy （ n = 36, 24% ） and idiopathic pericarditis （n = 35, 23% ）. Large effusions were more likely＇ associated with malignancy （P 〈 0. 01 ）. Compared to the initial 5 years （from 1996 to 2000） , the incidence of tuberculous effusion was decreased but neoplastic effusion increased significantly in the recent 5 ）,ears （from 2001 to 2005 ）. Forty-four patients underwent percardiocentesis （tuberculous in 23, neoplastic in 16, and others in 5） and 28 patients required pericardectomy （tuberculous in 11 and neoplastic in 17）. One patient with tuberculous and 3 patients with neoplastic pericardial effusion died during hospitalization. Conclusion Tuberculosis remains the major cause of pericardial effusion, but neoplastic pericardial effusions are on the rise. Pericardial drainage or pericardectomy are often required for symptomatic relief in those with malignancy-caused pericardial effusion.

What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance?

BACKGROUND:Traditionally performed using a subxiphoid approach,the increasing use of point-of-care ultrasound in the emergency department has made other approaches(parasternal and apical)for pericardiocentesis viable.The aim of this study is to identify the ideal approach for emergency-physician-performed ultrasound-guided pericardiocentesis as determined by ultrasound image quality,distance from surface to pericardial fl uid,and likely obstructions or complications.METHODS:A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial eff usions.The images were reviewed for technical quality,distance of eff usion from skin surface,and predicted complications.RESULTS:A total of 166 pericardial effusions were identified during the study period.The mean skin-to-pericardial fl uid distance was 5.6 cm(95%confi dence interval[95%CI]5.2-6.0 cm)for the subxiphoid views,which was signifi cantly greater than that for the parasternal(2.7 cm[95%CI 2.5-2.8 cm],P<0.001)and apical(2.5 cm[95%CI 2.3-2.7 cm],P<0.001)views.The subxiphoid view had the highest predicted complication rate at 79.7%(95%CI 71.5%-86.4%),which was signifi cantly greater than the apical(31.9%;95%CI 21.4%-44.0%,P<0.001)and parasternal(20.2%;95%CI 12.8%-29.5%,P<0.001)views.CONCLUSIONS:Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach.The distance from skin to fl uid collection is the least in both of these views.

Yellow nail syndrome accompanied by minimal-change nephrotic syndrome:A case report

BACKGROUND In most cases of yellow nail syndrome(YNS),the classic triad of yellow nails,lymphedema and respiratory manifestations rarely manifest simultaneously.Therefore,diagnosis is delayed or frequently missed.CASE SUMMARY We report a 62-year-old YNS patient presenting with bilateral pleural,pericardial and peritoneal effusions who,2 mo later,developed minimal-change nephrotic syndrome.After treatment with vitamin E,clarithromycin and prednisone for 3 mo,effusions in the chest,pericardium and abdominal cavity decreased while urine protein levels returned to within normal ranges.CONCLUSION Clinicians should consider the possibility of YNS for patients presenting with multiple serous effusions and nephrotic syndromes.

Cardiac tamponade as a rare complication after giant coronary fistula percutaneous closure

We present the case of an unusual complication after percutaneous closure of a giant coronary artery fis-tula. A 76-year-old man with previous admissions due to right heart failure and previous history of atrial fibrillation under acenocumarol, was admitted to our hospital for new onset of symptoms, characterized by progressive dyspnoea and peripheral edema. Physical examination revealed signs of congestive heart failure and a continuous murmur loudest along the lower sternal border. X-Ray showed cardiomegaly due to right chambers dilatation. Transthoracic echocardiography showed right chambers pressure and volume overload, with right ventricular enlargement and dysfunction, tricuspid annulus dilatation and severe tricuspid regurgitation. Cardiac catheterization showed significant elevation of right atrial pressure, as well as significant step-up of oxygen saturation in this chamber. Coronary angiography revealed the presence of a large fistula between the circumflex coronary artery (CCA) and coronary sinus (CS), with severe dilation of the CCA (maximum diameter20 mm). An Amplatzer? PDA was implanted in a distal elbow of the fistula with initailly good results. Anticoagulant therapy was then reinitiated, and a few days later, the patient developed clinical worsening of heart failure and dyspnoea. Echocardiogram showed significant pericardial effusion. Pleuropericardial window was then made draining a500 cm3 of bloody pericardial effusion. The postoperative outcome was excellent, with symptomatic relief and no signs of heart failure.

Primary gastric signet ring cell carcinoma presenting as cardiac tamponade

Primary gastric signet ring cell carcinoma presenting as cardiac tamponade is difficult to diagnosis early. Patients are generally asymptomatic until the disease is advanced. General practitioners usually focus on the initial symptoms related to pericarditis and pericardial effusion. We report a case of signet-ring cell carcinoma of the stomach presenting as cardiac tamponade with pericarditis and pericardial effusion but without any gastrointestinal symptoms. A 49-year old woman was admitted because of progressive dyspnea and cough. Chest X-ray revealed an increased cardiothoracic ratio and a small amount of bilateral pleural effusion. Two dimensional ultrasonographic echocardiography pericardial effusions with atrial and right ventricular early diastolic collapse were found, establishing the diagnosis of cardiac tamponade. Pericardiocentesis was performed and 420 mL of bloody ?uid was taken. The patient died of respiratory failure and cardiac arrest on October 28, 2009. Post-mortem examination revealed diffuse gastric mucosa erosion and edema with stomach mucosa incrassation in the greater curvature. The primary lesion was histopathologically diagnosed as signet-ring cell carcinoma of the stomach.

Tuberculous pericarditis-a silent and challenging disease:A case report

BACKGROUND Tuberculous pericarditis(TP)remains a challenge for endemic countries.In developing countries,one to two percent of patients with pulmonary tuberculosis develops TP.CASE SUMMARY A 49-year-old woman presented with dyspnea,chest pain and dry cough.On physical examination,veiled heart sounds were found.The electrocardiogram showed low-voltage complexes and the transthoracic echocardiography revealed a large and free-looking pericardial effusion.The patient was taken for an open pericardiotomy.The pericardial fluid revealed high levels of adenosine deaminase and Ziehl-Neelsen stain showed acid-fast bacilli.Polymerase chain reaction study for Mycobacterium tuberculosis in pericardial fluid was positive.The patient received tetra conjugate management with adequate clinical response after the first week of treatment and resolution of fever and chest pain.CONCLUSION In cases of TP,obtaining pericardial fluid and/or pericardial biopsy is the most efficient strategy to confirm the diagnosis.Early diagnosis of this entity will allow physicians to initiate timely treatment,avoid complications and improve the patient's clinical outcome,so we consider the description of this case pertinent and its review in the literature.

Cough induced syncope:A hint to cardiac tamponade diagnosis

We report a case of a 75-year-old male with history oflung adenocarcinoma who presented with shortness of breath and frequent episodes of cough-induced syncope. A large pericardial effusion was found on echocardiogram suggestive of cardiac tamponade. Pericardiocentesis was done which improved the dyspnea and eventually resolved the syncope. There are only two other cases reported in the literature with cough-induced syncope in the setting of pericardial effusion or cardiac tamponade. Our clinical vignette also highlights the importance of pulsus paradoxus identification in patients with cough induced syncope to rule out cardiac tamponade since this is the most sensitive physical finding for its diagnosis.