An Unusual Case of Shortness of Breath

Abstract

Purpose: A 49-year-old Vietnamese woman presented with a 4 week history of nonproductive cough, night sweats, and shortness of breath. She was afebrile and normotensive, but found to be tachycardic and tachypneic. Her lung exam revealed rales bilaterally. She had a single hard palpable supraclavicular lymph node. Notable labs upon admission included hemoglobin 9.9 g/dL and mean corpuscular volume of 73.5 fL. A chest x-ray showed bilateral interstitial and alveolar pulmonary opacities with increased confluence. On the night of admission, the patient became acutely hypoxic requiring 4 L of oxygen via nasal cannula to maintain her oxygen saturation above 90%. A transthoracic echocardiogram was performed and showed moderate circumferential pericardial effusion with early diastolic collapse of the right ventricular free wall which was consistent with cardiac tamponade physiology. The patient became hypotensive and did not respond to intravenous fluid resuscitation. She underwent a pericardial window with 400 mL of serous pericardial fluid evacuated. Her physical examination finding of a hard left supraclavicular lymph node was concerning for a gastrointestinal malignancy in the setting of iron deficiency anemia. Therefore, the patient underwent esophagogastroduodenoscopy which showed a 3 cm ulcerated mass in the lesser curvature of the stomach with areas of necrotic tissue and edematous borders, which was biopsied. The pericardial fluid, pericardium and gastric mass biopsies demonstrated poorly differentiated adenocarcinoma with diffuse signet ring features consistent with metastatic gastric adenocarcinoma (Figure 1). Generally, the most common malignancies to metastasize to the heart are melanoma, lung adenocarcinoma, and breast cancer. Gastric cancer metastasizes to the heart at lower rates and only rarely presents with cardiac tamponade. To our knowledge, this is the first reported case in the United States. Although unusual, cardiac tamponade secondary to metastatic gastric cancer should be considered when there is a combination of iron deficiency anemia, Virchow's node on examination, and chest x-ray findings concerning for lymphangitic carcinomatosis.Figure: [668]