CARDIAC TAMPONADE UNMASKING AN OCCULT MALIGNANCY IN A YOUNG WOMAN

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pericardial involvement secondary to cancer is mainly the result of metastatic disease and is associated with a poor prognosis (1). The most common tumors involving the pericardium are lung and breast, hematologic malignancies and gastrointestinal cancer (1). Cardiac tamponade with hemodynamic instability occurs in 50% of patients with malignant pericardial effusions (1). We present the case of a 24-year-old woman with cardiac tamponade secondary to primary lung adenocarcinoma. CASE PRESENTATION: A 24-year-old female without medical history presented with progressive shortness of breath accompanied by orthopnea and paroxysmal nocturnal dyspnea for 3 days. She denied fever, cough, chest pain, palpitations or syncope. On admission patient was hemodynamically stable, afebrile, tachycardic, tachypneic and requiring 2L of oxygen to maintain SpO2 of 92%. Physical exam was significant for labored breathing with decreased breath sounds bilaterally. EKG showed sinus tachycardia. Chest CT with contrast was negative for pulmonary embolism but revealed a right pleural effusion, a 2.6 cm pulmonary nodule in right lower lobe and a large pericardial effusion. A few hours later, patient became hypotensive (80/62 mm Hg). Bedside echocardiogram showed tamponade physiology. Emergent pericardiocentesis was performed with drainage of 700 mL of bloody fluid and concomitant right thoracentesis with removal of 600 ml of straw-colored fluid. Pleural fluid was negative for malignancy. However, pericardial fluid was positive for metastatic adenocarcinoma consistent with lung primary. She was diagnosed with stage IV metastatic lung adenocarcinoma and started on chemotherapy with Carboplatin and Pemetrexed. Molecular studies were sent to determine targeted therapy. OBGYN was consulted for fertility preservation. DISCUSSION: A hemorrhagic effusion in a young female patient should prompt investigation for metastatic cancer, lymphoma, autoimmune disorders, tuberculosis and HIV (2). Acute pericardial disease is a sign of underlying malignancy in 4-7% of cases, usually primary lung cancer (2). The standard of care for pericardial tamponade in the setting of a neoplastic disease is pericardiocentesis (1, 2). Cytology is the gold standard of a malignant pericardial effusion with a sensitivity of 71-92% and specificity of nearly 100% (1). It is superior to pericardial biopsy (1). Systemic chemotherapy with pericardial window is more effective than the former treatment alone (2). Chemotherapy combined with molecular targeted therapy was found to have a median survival of 4.5 months (2). CONCLUSIONS: Cardiac tamponade can be the initial manifestation of an underlying cancer and should be considered in the young population. A multidisciplinary team of cardiologists, oncologists, obstetrics, and intensivists is required to provide optimal care. Reference #1: Imazio M, Colopi M, De Ferrari GM. Pericardial diseases in patients with cancer: contemporary prevalence, management and outcomes. Heart 2020; 106(8): 569-574. Reference #2: Richard I, Robinson B, Filice G et al. Primary Lung Adenocarcinoma Presenting with Pericardial Tamponade in a Young Adult: A Rare Case Presentation. Cureus 2020; 12 (1): 1-10 DISCLOSURES: No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by John Makram, source=Web Response No relevant relationships by Barbara Mantilla, source=Web Response No relevant relationships by Pablo Paz, source=Web Response No relevant relationships by Myrian Vinan Vega, source=Web Response No relevant relationships by Ty Whisenant, source=Web Response