The silent hydropericardium in pregnancy: Avoidable pericardiocentesis with emergency cesarean section saves life

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

A Case of Persistent Right Ventricular Failure after Rapid Decompression of a Large Chronic Pericardial Effusion

Perioperative implications of pericardial effusions and cardiac tamponade

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem inflammation and is a common cause of pericarditis and pericardial effusion, but significant pericardial effusion and cardiac tamponade are rare and even rarer as the first manifestation. We report the case of a young male who presented with fever, recurrent pericarditis, and polyserositis with pericardial and bilateral pleural effusion. On examination, he was haemodynamically unstable and the pericardial effusion had considerable dimensions and an urgent pericardiocentesis was performed. Antinuclear antibody with a speckled pattern was positive, complement C4 levels were low, and the remaining autoimmunity and infectious study was unremarkable. Considering the European League Against Rheumatism/American College of Rheumatology classification criteria for SLE, a score of 11 points was obtained, confirming the diagnosis of SLE. This case report illustrates a rare form of presentation of SLE, in which the first manifestation was pericarditis with polyserositis and cardiac tamponade.

Granulomatosis With Polyangiitis (Wegener's Granulomatosis) Complicated by Pericarditis: Our Experience of Two Cases and Comparative Review of Literature

The most common kind of leukemia in adults is chronic lymphocytic leukemia (CLL). CLL is treated with ibrutinib. During the course of ibrutinib therapy, bleeding and cardiac arrhythmias may occur. Non-hemorrhagic adverse events are extremely infrequent in individuals using ibrutinib. A 64 year-old man was diagnosed with CLL in June 2016. He was treated with 6 courses of FCR, he stayed in remission for 3 years and then relapsed. He achieved partial remission after two months of therapy with ibrutinib. The patient was admitted to the hospital with fever and shortness of breath. Pericardial tamponade and effusion was diagnosed during his evaluation. Non-hemorrhagic exudative effusion was drained by pericardiocentesis and a pericardial catheter was inserted to drain pericardial effusion. In all pleural and pericardial effusion samples, pathological and flow cytometric examination revealed no atypical malignant cells for malignancy, including CLL. Infections, both bacterial and viral, were also undetectable in the samples, as were rheumatological markers of collagen vascular disease. Ibrutinib therapy was discontinued. The pericardial effusion and tamponade were linked to ibrutinib treatment after evaluating the adverse drug reaction probability scale with a total score of 6. Colchicine was administered to reduce the pericardial effusion. The catheter was removed; pericardial effusion did not reoccur during follow up visits. Serious adverse events of ibrutinib are seen when treating CLL patients. This group of individuals should be closely monitored for potentially serious complications such as pericardial effusion and cardiac tamponade.

The pericardium is a hard, fibroelastic sac that encloses the heart, with the ability to stretch appreciably in dogs tormented by pericardial effusion (PE) (Lorell and Braunwald, 1984). PE is characterized with the aid of a bizarre buildup of fluid in the pericardial space, at the same time as small volumes of PE won’t produce medical signs and symptoms, will increase in fluid volume and pressure can cause cardiac tamponade. The most common causes of PE in dogs are cardiac neoplasia, right sided heart failure, cardiac rupture, and idiopathic pericarditis and less commonly congenital pericardial disorders, trauma, or infectious origin. Pericardial tumors can make contributions to both pleural and pericardial effusions in dogs (Scollan et al., 2015). Blood analysis might also display mild anaemia and leukocytosis in cases regarding pericardial tumors, in particular haemangiosarcoma (Shaw and Rush 2007). The common physical findings in dogs with pericardial and pleural effusion encompass Muffled heart sounds, jugular vein distention, tachycardia, abdominal distension, abdominal respiration, poor pulse quality, ascites, dyspnea, and tachypnea (Kladakis et al, 2018). In lateral thoracic radiographs, the coronary heart often seems globoid or rounded. PE is now and again mistaken for dilated cardiomyopathy (DCM), and pleural effusion may also be seen on radiographs. Common ECG findings in dogs with PE encompass sinus tachycardia, ventricular arrhythmias, low voltage QRS complexes, ST phase elevation, and electrical alternans (Guglielmini et al., 2012). Echocardiography is a non-invasive and enormously effective diagnostic tool for detecting even small amounts of PE. The presence of PE itself complements visualization of the masses on the heart, because the fluid acts as a assessment medium (MacGregor et al., 2005). Echocardiography is considered the gold standard well known for diagnosing PE and formulating a therapeutic plan (Shaw and Rush, 2007). Treatment for pericardial and pleural effusion consists of pericardiocentesis and thoracocentesis, respectively, at the side of diuretic remedy. Chemotherapy may be considered in instances of cardiac neoplasia (Shaw and Rush, 2007). This communication reports successful management of pericardial and pleural effusion in a dog with pericardial mass.

Dear Editor, Myxedema heart disease is a well-known entity. Pericardial effusions have been reported in 50-73% of pediatric patients with hypothyroidism in various series (1, 2), but none of these describes the symptomatic pericardial effusions or cardiac tamponade. A 5- year-old female child presented with complaints of periorbital puffiness and mild abdominal distension intermittently for last 6 months. She was symptomatically treated with diuretics off and on without much benefit. This time she reported to pediatric emergency with progressively increasing respiratory distress for last 5 days. There was no history of any fever, decreased urine output, orthopnea, or Koch’s contact. She was third live issue of non-consanguineous marriage born by normal vaginal delivery following uncomplicated pregnancy. She was immunized for age with no significant family history. She had history of global development delay; development age corresponded to 3 years. On examination she was afebrile with HR of 70/min, RR of 44/min and BP of 80/60 mmHg with pulsus paradoxus. She had coarse facies with dilated neck veins. Her skin was dry and coarse. She had short stature with height less than 3rd centile and normal weight. Her cardiovascular examination revealed silent precordium. Her cardiac border was extending 1.5 cm beyond right sternal margin and 2 cm beyond apex beat on left side on percussion. Her heart sounds were muffled with no murmur. Her abdominal examination revealed free fluid in abdomen. Rest of systemic examination was normal. Chest X ray revealed massive cardiomegaly with CT ratio of 678%. Immediate ECHO done on urgent basis, revealed large pericardial effusion with collapse of right atrium during diastole with ejection fraction of 65% and intrinsically normal heart. ECHO guided pericardiocentesis drained 150 ml of fluid. The fluid was clear with 3.3 mg/dl of proteins, 110 mg/dl cholesterol, 20 RBC/µL, 14 lymphocytes/µL, 7 neutrophils/µL and rest of pericardial examination were normal. Rest of hematological and urinary examination was normal. Searching for tuberculosis was also negative. In view of features suggested of hypothyroidism on clinical examination and non infectious nature of pericardial fluid, her thyroid profile was done which was suggested of hypothyroidism with T3 = 0.92 nmol/L (1.39-3.7nmol/L), T4 = 3.2 µg/dl (5.5-12.8µg/dl), TSH= 40 mIU/L(0.7-6.4 mIU/L). Her anti TPO antibodies were negative and USG neck revealed mild enlargement of thyroid gland. She was started on L-thyroxine with dosage of 4 µg/kg/d. She responded to treatment with thyroid replacement and her pericardial effusion disappeared after 2 months on repeat ECHO. She is on regular follow up and showing improvement in each regards. Although mild to moderate pericardial effusions of no clinical significance are frequently reported in pediatric myxedema heart disease, but cardiac tamponade is rare. Literature reports only 2 adolescent girls with cardiac tamponade in association with hypothyroidism, but none has been reported in young children. Author reports a rare case of cardiac tamponade in a young child with previously unrecognized hypothyroidism. Besides bradycardia, minimal pericardial effusions are most common cardiac manifestations of clinical hypothyroidism in adults. Most of pediatric age group patients presenting with this belonged to neonatal period or to Down’s syndrome (1, 2). Myxedema heart disease was first described by Zondek in 1918 and was completely defined by Fahr in 1925 (3). The pathophysiological derangements responsible for pericardial effusions are increased egress of proteins from blood, decreased lymphatic clearance of proteins and abnormal electrolyte metabolism (4). At molecular level, commonly observed signs or symptoms in hypothyroidism are attributed to changes in expression of various gene products, which includes alpha myosin heavy chain, beta-1 adrenergic receptors, voltage gated potassium channels and sarcoplasmic reticulum calcium ATPase (5). The rarity of cardiac tamponade in hypothyroidism is attributed to slow accumulation of fluid and marked distensibility of pericardium (6). Alexander first described ‘Gold paint effusion’ to describe the golden brown appearance of pericardial fluid due shimmering satin cholesterol crystals (7). High cholesterol content of pericardial fluid have been attributed to disturbance of lipid metabolism; probably churning action of heart causing precipitation of cholesterol from pericardial fluid. Treatment of cardiac tamponade due to hypothyroidism involves urgent pericardiocentesis followed by thyroxine replacement. Treatment of pericardial effusion with thyroxine replacement leads to resolution of effusion in 2-12 months (5). In conclusion myxedema heart disease should be suspected in any child with symptoms suggestive of hypothyroidism, presenting with even hemodynamic-ally significant pericardial effusion or cardiac tamponade. Patients with hypothyroidism-associated pericardial effusion should be monitored for development of cardiac tamponade.

LOW-PRESSURE CARDIAC TAMPONADE: A RARE COMPLICATION IN THOSE UNDERGOING HEMODIALYSIS WITH KNOWN PERICARDIAL EFFUSION

INTRODUCTION/BACKGROUNDHypothyroidism is associated with multiorgan involvement and various complications. Pericardial effusion is a rare complication of hypothyroidism. However, if left untreated, it may progress to critical, life-threatening conditions such as cardiac tamponade and hemodynamic instability. Early identification of the diagnosis, with effective management of pericardial effusion in hypothyroidism, is essential. CASEA 67-year-old female with hypothyroidism since 2016 presented with worsening exertional dyspnoea, bilateral lower limb swelling, and fatigue. She had a background history of hypertension and bronchial asthma. She had elevated jugular venous pressure, but no muffled heart sounds. Her ECG showed small-voltage QRS complexes, and chest X-ray revealed cardiomegaly with pulmonary congestion. Her echocardiography showed a large pericardial effusion with a collapse of the right ventricle. An urgent pericardiocentesis was performed, and her symptoms improved after draining 500 cc of pericardial fluid. TFT showed elevated TSH (83.42 m IU/L) with normal free T4 (13.5 pmol/L). She had markedly elevated anti-thyroid peroxidase (>600 IU/mL) and anti-thyroglobulin (>4000 IU/mL). Her pericardial fluid investigations were unremarkable. The patient has been taking her levothyroxine inconsistently with her meals. Her levothyroxine dose was increased from 100 mcg to 150 mcg daily. She showed improvement by the third day of hospitalisation. She was discharged and advised to adhere to the levothyroxine. Her subsequent TFTs normalised with normal echocardiography during the follow-up visit. Hypothyroidism causes protein-rich pericardial effusion due to increased membrane permeability, increased albumin distribution volume, and diminished lymphatic drainage, which happens gradually over time. CONCLUSIONPericardial effusion in hypothyroidism is an infrequent entity. It is more frequent in long-standing clinical hypothyroidism than subclinical hypothyroidism. An early cardiac assessment, adequate thyroid replacement therapy, and medication adherence can help mitigate the risk of pericardial effusion or cardiac tamponade.

BackgroundPericardial effusion is common in patients with systemic sclerosis (SSc) but often mild and asymptomatic. Cardiac tamponade or severe pericardial effusion are very rare but they can be the first...

A previously healthy 50-year-old Chinese woman presented with a low-grade fever, a generalized headache, and chest pain of 2 to 3 weeks’ duration. She described intermittent sharp chest pain over the precordium that intensified when she lay down and shortness of breath after minimal exertion. Despite having lost her appetite, she had gained ≈10 pounds during the past month and had noticed ankle swelling. She denied having had arthralgia or skin rash and had not experienced any nocturnal dyspnea, wheezing, cough, expectoration, or hemoptysis. She had visited her relatives in the Middle East 6 months earlier, but her past medical history was uneventful. She had taken acetaminophen (Tylenol) tablets and a Chinese herbal preparation, but her symptoms continued. On physical examination, she appeared weak and ill. Her temperature was 36.7°C (98.0°F), and her pulse was 110 beats per minute, regular, and had normal volume and character. Her blood pressure was 115/70 mm Hg, which decreased to 90/70 mm Hg on inspiration; her respiratory rate was 22 breaths per minute. Carotid pulsations were normal. Jugular veins were distended to the angle of the mandible when the patient sat upright, but no further venous engorgement was noted on inspiration. There was mild mucosal pallor, but the oropharynx was otherwise normal. The first and second heart sounds were normal, and there were no clicks or gallops. A superficial scratchy systolic sound was heard intermittently over the left lower sternal region. Dullness to percussion, scattered inspiratory crackles, and diminished air entry were evident over both lung bases. Abdominal examination demonstrated a soft, tender liver palpable 2 cm below the right costal margin. Her pelvis and rectum showed no abnormality. A stool guaiac test was negative. Neurological examination was normal. There was moderate pitting edema below the level of the knees. Results of the initial …

Giant Thymoma and Cardiac Tamponade

Diagnosing pericardial effusion is critical for optimal patient care. Typically, clinicians use physical examination findings 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. 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 findings associated with pericardial effusion and tamponade were determined. 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 finding of Beck's triad to diagnose pericardial tamponade was 50% (28.0%-72.0%). 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.

The Diagnosis of Pericardial Effusion and Cardiac Tamponade by 12-Lead ECG: A Technology Assessment