Abstract 13015: Cardiac Tamponade as a Rare Presentation of Chronic Lymphocytic Leukemia

Abstract

An 89 year old male with a past medical history of CAD , diastolic HFpEF, HTN, HLD, DM, sick sinus syndrome with permanent pacemaker, OSA presented to the office with complaints of fatigue and progressive exertional dyspnea for 2 weeks. On examination his BP was 86/61mm Hg with a systolic drop of 20mmhg during inspiration by palpatory method, RR was 24 breaths/min, HR was 64 bpm, O2 sat. was 85% on RA. JVP was raised at 15cm. Cardiopulmonary examination revealed distant heart sounds, bibasilar crepitations and mild bilateral pedal eema. No lymphadenopathy was palpable. Initial lab assessment showed Hb of 9.5gdl, WBCs of 14.3 K/ul, potassium of 6.2mmol/, increased BUN/Creatinine ratio of 67/1.7, LDH of 642 U/L, Troponin I of 0.04ng/ml and BNP of 338pg/ml. EKG demonstrated av-paced rhythm without any evidence of electrical alternans or low voltage. CXR showed significant cardiomegaly. Transthoracic echocardiogram revealed normal LV cavity size, wall thickness and systolic function. A large pericardial effusion with early right ventricular diastolic collapse suggesting tamponade. The patient underwent emergent closed pericardiocentesis with complete resolution of symptoms. . Pericardial fluid analysis showed glucose of 78mg/dl, protein of 4.2g/dl, PH of 7.21, LDH of 1913 U/L, 1195000/uL RBCs, 212427/uL nucleated cells(Differential count N 3%, L 93%, M 2%, E 2% and B 0). Cytology was positive for PAX-5, CD-5 and negative for Cyclin-D1 & CD-10 which was consistent with CLL. The patient was evaluated by the oncologist and he was started on rituximab and bendamustine. Follow up echocardiograms did not show any recurrence of effusion. The presence of pulsus paradouxs with other signs including hypotension, muffled heart sounds and raised jugular venous pressure greatly increases its sensitivity for cardiac tamponade which was evident in this case. Our case is unique because cardiac tamponade is rarely reported as an initial presentation of Chronic Lymphocytic Leukemia.