Large Effusion Research Articles

125 Cardiac Parasternal Long Axis View in Isolation: Is it Good Enough to Identify Pericardial Effusion, Left Ventricular Dysfunction and Right Ventricular dilation?

Transthoracic focused cardiac ultrasound (FOCUS) is used clinically to identify etiologies of undifferentiated hypotension and shortness of breath in the emergency department (ED) and used to guide acute treatment. While a 4-view FOCUS examination is preferred to evaluate these patients, it is not always feasible due to patient body habitus, medical co-morbidities and clinician time constraints. The primary goal of this study was to determine the diagnostic accuracy of the parasternal long axis (PSLA) view in isolation for identifying pericardial effusion, left ventricular (LV) dysfunction and right ventricular (RV) dilation when compared to a 4-view FOCUS examination. This was a retrospective study looking at FOCUS images obtained on ED patients with a cardiovascular complaint. Examinations were blinded and randomized for review by point of care ultrasound faculty. Three faculty reviewed a full 4-view examination, while 2 others independently reviewed all PSLA images in isolation. Disagreements were adjudicated by a third reviewer. The primary objective was measured by comparing ultrasound findings on PSLA view in isolation to findings on a full 4-view FOCUS exam which served as the criterion standard. Sensitivity and specificity were calculated, as well as interobserver agreement using Kappa. We analyzed data on 100 FOCUS examinations; 16% had a pericardial effusion, 41% had an LV ejection fraction <50% (moderately reduced to poor LV function), 7% had RV dilation. Sensitivity and specificity for identifying pericardial effusion, LV dysfunction and RV dilation was 81% (confidence interval [CI] 0.54-0.95) and 98% (CI 0.91-0.99), 100% (CI 0.88-1) and 91% (CI 0.80-0.97), and 71% (CI 0.30-0.94) and 99% (CI 0.93-1), respectively. All moderate to large effusions were correctly identified. Interobserver agreement for faculty reviewing the PSLA images in isolation was k=0.72. Overall, there were 13 disagreements between PSLA alone and the 4-view interpretations. Four were clinically significant; 3 misclassifications of RV dilation, and 1 exam with normal LV ejection fraction on 4-view interpreted as severely reduced on PSLA view. The PSLA view in isolation is highly specific for identifying pericardial effusion and RV dilation, but only had moderate sensitivity. This single view had high sensitivity and specificity for diagnosing moderate to poor LVEF. This data supports the use of a single PSLA view for evaluating LVEF and ruling out moderate to large pericardial effusions. More views are necessary to rule out RV dilation.

IN A TIME OF VIRAL SPREAD, DON'T FORGET THE USUAL SUSPECTS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The diagnosis of lung malignancy can often be incidental. We present a hemodynamically unstable patient with COVID-19 and pericardial effusion, subsequently diagnosed with metastatic adenocarcinoma of the lung. CASE PRESENTATION: A 54-year-old male with no significant medical history was diagnosed with COVID-19 two weeks prior to presentation. He had dyspnea on exertion since that time and presented to the hospital after having an abnormal CXR and leukocytosis on out-patient testing. His blood pressure was 95/68 with a heart rate of 129. EKG revealed atrial fibrillation and electrical alternans. He had mildly elevated BNP and troponin, with lactic acidosis. Bilateral opacities were noted on CXR. A large effusion concerning for tamponade was noted on bedside echo. He underwent immediate pericardiocentesis and had 2L serosanguinous fluid drained. After initial stabilization, he was found to have extensive bilateral lower extremity DVT and PE.Repeat TTE showed residual effusion with tamponade physiology observed. Despite the findings on imaging, a pericardial window was not pursued due to concerns of anesthesia induction in the setting of a new PE. He underwent placement of a pericardial drain instead. After the procedure, heparin drip was initiated with an IVC filter placed soon after. The patient eventually had a pericardial window placed. His arrhythmia was chemically converted back to sinus rhythm. On POD5, the drains were removed.Autoimmune workup of the fluid was within normal limits, but cytology resulted in a diagnosis of adenocarcinoma positive for TTF-1. Thus, he was diagnosed with stage IV adenocarcinoma of the lung. CT revealed multiple lytic lesions with diffuse lymphadenopathy. MRI showed no evidence of brain metastasis. He was transitioned to apixaban at discharge, with out-patient oncology follow-up. DISCUSSION: A small study of 31 patients showed pericardial effusion was an independent risk factor predicting severity of COVID-19 infection, with reports of the virus being detected in pericardial fluid.[1,2] While virus infection can cause pericardial effusion, other causes should not be ignored in the workup. With hemodynamic instability, immediate intervention is warranted despite the risk involved with pericardiocentesis. In patients with large volume of pericardial effusion extracted, 5% of them will suffer from paradoxical hemodynamic instability and pulmonary edema afterwards, a condition known as pericardial decompression syndrome.[3] The increased venous return after decompression will compress the LV, based on the principle of ventricular coupling, reducing the cardiac output. Treatment for this condition is supportive. CONCLUSIONS: While COVID-19 is known to cause pericardial effusion, other causes, such as malignancy, should not be forgotten and should always remain in our differential. The risk involved with immediate pericardiocentesis goes beyond cardiac injury. REFERENCE #1: Chen Q, Xu L, Dai Y, et al. Cardiovascular manifestations in severe and critical patients with COVID -19. Clin Cardiol. 2020;43(7):796-802. REFERENCE #2: Farina A, Uccello G, Spreafico M, Bassanelli G, Savonitto S. SARS-CoV-2 detection in the pericardial fluid of a patient with cardiac tamponade. Eur J Intern Med. 2020;76:100-101. REFERENCE #3: Prabhakar Y, Goyal A, Khalid N, et al. Pericardial decompression syndrome: A comprehensive review. World J Cardiol. 2019;11(12):282-291. DISCLOSURES: No relevant relationships by Rumon Chakravarty, source=Web Response No relevant relationships by Vernon Chan, source=Web Response

BILATERAL CHYLOTHORAX AND ANASARCA CAUSED BY DASATINIB IN A PATIENT WITH CHRONIC MYELOGENOUS LEUKEMIA

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dasatinib is one of the tyrosine kinase inhibitors that is used in the treatment for Philadelphia positive Chronic Myeloid Leukemia (CML). Pleural effusion can occur in 10% of patients on dasatinib, but chylothorax was rarely reported as a side effect of dasatinib (1,2). CASE PRESENTATION: A 52 year-old male with medical history of CML presented with shortness of breath over the past 4months. Patient was diagnosed with CML 10 years ago. Initially he was started on imatinib which he did not tolerate secondary to headache and he was switched to dasatinib 100mg daily which he tolerated for 5 years. Bone marrow biopsy showed complete cytogenetic remission in 6-months and he achieved major molecular remission. Physical exam was remarkable for reduced air entry to both lungs, abdominal ascites, and lower extremities pitting edema up to the groins. Basic labs were within normal limits. Chest X-ray showed bilateral pleural effusions and confluent bibasilar infiltrates. Computed topography of the chest showed large bilateral effusions with passive atelectasis in the lower lobes (figure-1A and 1B). CT scan of the abdomen and pelvis showed diffuse body edema in the lower abdomen extending to both lower extremities. Large right hydrocele and moderate left hydrocele were also noticed (figure-1C). Imaging guided thoracentesis was performed on the right side and 1900 ml of milky fluid was drained. Pleural fluid analysis showed total protein of 4.6 g/dL (serum total protein:7.3 g/dL), glucose of 97 mg/dL (serum glucose: 84 mg/dL), elevated lactate dehydrogenase (116 U/L), elevated triglyceride (485 mg/dL), and elevated cholesterol (83 mg/dL). Based on that, Diagnosis of chylothorax was made and dasatinib was discontinued. Patient was started on short course of diuretics and oral prednisone. After one month of dasatinib discontinuation, patients SOB improved significantly. Abdominal and lower extremities swelling has improved too. Repeated CXR showed improved bilateral pleural effusion (figure-1D). We kept patient off dasatinib with monthly check of BCR/ABL by PCR with plan to restart dasatinib at 50 mg daily or switching to another treatment if he relapses. DISCUSSION: Pleural effusion is a known side effect of dasatinib and few reports of unilateral chylothorax have been reported. Bilateral chylothorax and anasarca are very rare side effects of dasatinib. In most of the cases, discontinuation of dasatinib can improve symptoms. In a previous case report, 63 year-old female presented with right sided dasatinib induced chylothorax which totally resolved after switching dasatinib to nilotinib (2). In another case report, the 71 year-old patient presented with dasatinib induced chylothorax that initially resolved and then recurred after re-initiation of dasatininb (3). CONCLUSIONS: Bilateral chylothorax after dasatinib is very rare. Most cases resolve completely with dasatinib discontinuation. REFERENCE #1: Kantarjian H, Shah NP, Hochhaus A, et al. Dasatinib versus imatinib in newly diagnosed chronic-phase chronic myeloid leukemia. N Engl J Med. 2010 Jun 17;362(24):2260-70. doi: 10.1056/NEJMoa1002315. Epub 2010 Jun 5. PMID: 20525995. REFERENCE #2: Al-Abcha A, Iftikhar MH, Abu Rous F, et al. Chylothorax: complication attributed to dasatinib use. BMJ Case Rep. 2019 Dec 16;12(12):e231653. doi: 10.1136/bcr-2019-231653. PMID: 31848139; PMCID: PMC6936595. REFERENCE #3: Chen B, Wu Z, Wang Q, et al. Dasatinib-induced chylothorax: report of a case and review of the literature. Invest New Drugs. 2020 Oct;38(5):1627-1632. doi: 10.1007/s10637-020-00932-3. Epub 2020 Apr 4. PMID: 32248338. DISCLOSURES: No relevant relationships by hamed daw, source=Web Response No relevant relationships by Christopher Haddad, source=Web Response No relevant relationships by Tariq Kewan, source=Web Response No relevant relationships by Talha Saleem, source=Web Response

MASSIVE SPONTANEOUS PLEURAL EFFUSION IN END-STAGE RENAL DISEASE PATIENT WITH VANCOMYCIN RESISTANT ENTEROCOCCUS EMPYEMA AND COVID-19 INFECTION

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pleural effusion is one of the most common complications seen in end-stage renal disease (ESRD) patients [1]. Here we report a case of massive spontaneous pleural effusion in an ESRD patient, who tested positive for coronavirus disease 2019 (COVID-19) on hospital admission, and later grew vancomycin resistant enterococcus (VRE) from the pleural space. CASE PRESENTATION: 79-year-old male with past medical history of ESRD on hemodialysis, hypertension, diabetes mellitus and history of prostate cancer presented with abdominal discomfort and progressive nausea and vomiting. COVID-19 test was positive on screening, although vital signs and review of systems were negative except as above. Labs were remarkable for leukocytosis, elevated blood urea nitrogen and creatinine. Chest X-ray showed nearly complete opacification of the left hemithorax associated with dense consolidation of the left lower lobe and the lingula. Computerized tomography scan showed a large complex fluid attenuating lesion involving the left hemithorax, which may represent a large loculated left-sided effusion versus a large left-sided empyema, resulting in mediastinal shift to the right and inferior displacement of the left hemidiaphragm. Pleural fluid was drained via pigtail catheter, and on analysis was found to be exudative with few leukocytes and no microorganisms. Due to septations of the hemithorax and development of hydropneumothorax, chest tube was placed and eventually video-assisted thoracoscopic surgery was performed for further drainage and decortication. Biopsy obtained during surgery showed no malignant cells; tissue culture and subsequent pleural fluid cultures were positive for VRE. DISCUSSION: Pleural effusion is a pathological finding that is often seen in ESRD patients with heart failure, pneumonia, pulmonary embolism, cancer and uremia [1]. Interestingly, our patient received regular hemodialysis, and presented with no signs of heart failure or fluid overload, making ESRD less likely to be a major or direct cause of the massive pleural effusion. Studies show VRE is prevalent in dialysis centers and frequently colonizes ESRD patients [2]. Rarely, VRE can cause empyema, as illustrated by Cotton in an asplenic patient with multiple co-morbidities who presented with pneumonia [3]. Our patient might have VRE colonized in his airway, so pleural cultures were positive after decortication. Additionally, COVID-19 infection has been associated with pleural effusion [4]. Hussein reported an acute accumulation of moderate exudative pleural effusion in a patient with no past medical history except for concurrent COVID-19 infection. As a result, the positive COVID-19 test in our patient might also contribute to his massive effusion. CONCLUSIONS: Factors like ESRD on hemodialysis, positive VRE in pleural tissue culture, as well as COVID-19 infection, may all contribute to the rare massive pleural effusion in our case. REFERENCE #1: Uzan, G. and H. Ikitimur, Pleural Effusion in End Stage Renal Failure Patients. Sisli Etfal Hastan Tip Bul, 2019. 53(1): p. 54-57. REFERENCE #2: Zacharioudakis, I.M., et al., Vancomycin-resistant enterococci colonization among dialysis patients: a meta-analysis of prevalence, risk factors, and significance. Am J Kidney Dis, 2015. 65(1): p. 88-97.Cotton, M.J. and C.D. Packer, Vancomycin-resistant Enterococcus faecium Empyema in an Asplenic Patient. Cureus, 2018. 10(8): p. e3227. REFERENCE #3: Hussein, M., et al., Pleural effusion as an isolated finding in COVID-19 infection. Respir Med Case Rep, 2020. 31: p. 101269. DISCLOSURES: No relevant relationships by Aram Hambardzumyan, source=Web Response No relevant relationships by Stephen Jesmajian, source=Web Response No relevant relationships by Liyun Liu, source=Web Response Speaker/Speaker's Bureau relationship with GSK Please note: approx 2016 to now Added 05/02/2021 by Michael Mandel, source=Web Response, value=Consulting fee No relevant relationships by Corina Nava, source=Web Response No relevant relationships by ABHISHEK NIMKAR, source=Web Response No relevant relationships by Carlos Romano, source=Web Response

THE BAD AND THE UGLY: A CASE OF COVID-19 AND TB CO-INFECTION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: For the last 100 years, the leading infectious cause of death has been tuberculosis (TB) – until 2020, when SARS-CoV2 became a global pandemic. As the incidence of COVID-19 rises, co-infection with TB is expected. CASE PRESENTATION: A 49-year-old Nepali male presented to the emergency room with cough, dyspnea, and lower extremity weakness. He reported anorexia and weight loss over several months. On presentation, he was afebrile with a heart rate of 118 beats/min, respiratory rate of 20 breaths/min, blood pressure of 156/115 mmHg, and oxygen saturation of 89%. Initial examination demonstrated an ill-appearing male with epidermoid cysts of the neck and cervical lymphadenopathy. Auscultation revealed diminished breath sounds bilaterally with intercostal retractions with breathing. Laboratory results included elevated transaminase, CRP, ferritin, and LDH levels. CT imaging showed large bilateral effusions, bilateral lung atelectasis and pleural thickening with no peripheral ground-glass pattern. The patient was screened for COVID-19 and subsequently tested for TB following the findings on imaging. SARS-CoV2 PCR and QuantiFERON gold test were positive on admission. The patient underwent serial diagnostic and therapeutic thoracentesis for his effusions, and the bilateral fluid AFB cultures were positive.Pleural thickening on the CT scan suggested a chronic disease process, without typical COVID-19 findings. Remdesivir, convalescent plasma and steroids were held following TB diagnosis as his presentation supported a more chronic disease trajectory rather than an acute progression of illness. The patient was initially placed on a high-flow nasal cannula and eventually weaned to room air throughout the hospital course with RIPE treatment. After 65 days, he was discharged to a rehab facility. DISCUSSION: The patient's hypoxemia was likely a result of chronic TB given imaging did not reveal typical findings of COVID-19. The presentation of bilateral pleural effusions caused by TB is a rare phenomenon as most cases demonstrate unilateral effusions. Pleural effusions in COVID-19 infection are usually found as a complication of prolonged illness or bacterial superinfections. Blunting the inflammatory response in COVID-19 with steroids can endanger a patient with active TB because it interferes with cellular immunity essential to containing mycobacteria. Although recent evidence suggests that COVID-19 infection severity is higher in the setting of TB co-infection, our patient demonstrated a mild COVID-19 infectious course. Despite his prolonged hospital course, he did not require intubation and his hypoxemia steadily improved. CONCLUSIONS: Our case demonstrates a previously undescribed case of COVID-19 superimposed on TB complicated by bilateral pulmonary effusions. When indicated, it is crucial to screen for both infections due to overlapping symptomatology and the prevalence of these diseases. REFERENCE #1: Mousquer GT, Peres A, Fiegenbaum M. Pathology of TB/COVID-19 Co-Infection: The phantom menace. Tuberculosis (Edinb) 2021;126:102020. REFERENCE #2: Bandyopadhyay A, Palepu S, Bandyopadhyay K, Handu S. COVID-19 and tuberculosis co-infection: a neglected paradigm. Monaldi Arch Chest Dis 2020;90(3). REFERENCE #3: Vorster MJ, Allwood BW, Diacon AH, Koegelenberg CFN. Tuberculous pleural effusions: advances and controversies. J Thorac Dis 2015;7(6):981–991. DISCLOSURES: No relevant relationships by Saad Ahmad, source=Web Response No relevant relationships by Klaus Meinhof, source=Web Response No relevant relationships by Reiichiro Obata, source=Web Response

French hip resurfacing registry: A study of 1650 cases

BackgroundHip resurfacing has been the focus of many evaluations based on international registries but, to date, no prospective studies have evaluated this procedure in France. In 2015, the French Society for Orthopaedics and Traumatology (SoFCOT) and the French Hip and Knee Society concluded an agreement with the French Medicines Agency (ANSM) and French National Health Authority (HAS) to establish an exhaustive observational hip resurfacing registry. The primary objective of this study was to evaluate the hip resurfacing survival rate since the creation of the registry 5 years ago. The secondary objectives were to evaluate the clinical, functional, and radiological outcomes of hip resurfacing and to check the absence of specific complications related to this implant. HypothesisThe hypothesis was that the registry survival rate was below 0.5% per year. MethodsSince 2015, data from all patients undergoing hip resurfacing were collected into a monitored database using the software suite OrthoWave. The following were collected for each patient: demographics, anthropometric characteristics, clinical parameters (Postel Merle d’Aubigné score, Harris Hip Score, Oxford Hip Score, and UCLA Activity Score), and radiological findings. Completeness of data collection was checked once a year. ResultsIn total, 1650 hip resurfacings in 1506 patients (1409 males and 97 females) with a mean age of 50.7 years (range, 17–70 years) were included. Mean follow-up was 3.8 years (range, 2–4.8 years). Mean completeness of data recording was 98.2%. All clinical scores improved significantly. Hip revision was required for 7 (0.4%) complications including 4 femoral neck fractures, 1 aseptic lymphocyte-dominant vasculitis-associated lesion with a large joint effusion, 1 femoral component loosening, and 1 delayed sepsis requiring bipolar removal. At 5 years, the survival rate without hip revision for any cause was 99.6% (95% confidence interval, 99.3–100%). DiscussionThe short-term outcomes of patients in the French registry are encouraging in terms of complication and surgical revision rates. The near absence of complications related to metal-on-metal bearing surfaces demonstrates that the criteria used in France (at least 48mm head diameter, use of implants for which long-term data are available, and specific training of surgeons) ensure successful long-term outcomes. Level of evidenceII.

A Soccer Fan’s Pain In The Elbow

HISTORY: A 35-year-old right-hand dominant male soccer fan presents with 3 days of acute right elbow pain. He began to experience progressive right lateral elbow pain while clapping exuberantly during a Seattle Sounders come from behind victory. He could recall no other trauma or inciting event. He had noticed some mild elbow soreness a few days preceding acute onset of pain. He endorsed elbow warmth and swelling as well as severe pain with any movement. He denied numbness, tingling, chills, fevers, fatigue, malaise. No prior history of rheumatic disease or gout. An x-ray obtained prior to presentation to our clinic showed small elbow joint effusion which the radiologist noted was suspicious for occult radial head fracture. PHYSICAL EXAMINATION: Swelling of right elbow with mild erythema. Decreased passive and active range of motion with elbow flexion, elbow extension, pronation, and supination. Tenderness to palpation overlying radial head as well as to olecranon bursa. Resisted wrist extension reproduced symptoms. Neurovascular exam was normal. DIFFERENTIAL DIAGNOSIS: 1. Occult radial head fracture 2. Lateral epicondylitis 3. Radial tunnel syndrome 4. Septic arthritis 5. Inflammatory arthropathy TEST AND RESULTS: X-ray: A small joint effusion suspicious for occult radial head fracture was noted. Ultrasound: Large elbow joint effusion tracking from the radiocapitellar joint deep to the triceps tendon insertion posteriorly. Common extensor tendon was intact. No swelling of the radial nerve visualized. Joint Aspiration: Joint aspiration revealed initially bloody then cloudy fluid. No organisms on gram stain or culture. Cell count revealed inflammatory joint aspirate containing over 50,000 WBCs of which 95% were neutrophils. Intracellular monosodium urate crystals were identified. FINAL WORKING DIAGNOSIS: Acute gout flare of right elbow TREATMENT AND OUTCOMES: Radiocapitellar joint steroid injection was performed due to ongoing pain despite oral NSAID use. Elbow pain resolved approximately 1 week after the injection. Dietary considerations were discussed. Patient advised to discuss uric acid lowering agents with PCP.

Combined Inhibition of Akt and mTOR Is Effective Against Non-Hodgkin Lymphomas.

Non-Hodgkin lymphoma (NHL) are a diverse group of hematological malignancies comprised of over 60 subtypes. These subtypes range from indolent to aggressive. The PI3K/Akt/mTOR pathway has been shown to contribute to cell survival and proliferation and is constitutively active in most NHL. MK-7075 (miransertib) and MK-4440 are small molecules that effectively inhibit Akt and have entered clinical development. Using in vitro and in vivo models of NHL, we explored targeting the kinase Akt with miransertib and MK-4440 alone or in combination with the mTORC1 inhibitor, rapamycin (sirolimus). Both Akt inhibitors inhibited the pathway and NHL proliferation in a subtype-dependent manner. However, these compounds had a minimal effect on the viability of primary B-cells. Importantly, the combination of miransertib and sirolimus synergistically reduced cell proliferation in NHL, including in one indolent subtype, e.g., follicular lymphoma (FL), and two aggressive subtypes, e.g., diffuse large B-cell lymphoma (DLBCL) and primary effusion lymphoma (PEL). To establish in vivo efficacy, we used several xenograft models of FL, DLBCL, and PEL. The results obtained in vivo were consistent with the in vitro studies. The FL xenograft was highly sensitive to the inhibition of Akt alone; however, the tumor burden of PEL xenografts was only significantly reduced when both Akt and mTORC1 were targeted. These data suggest that targeting the PI3K/Akt/mTOR pathway with Akt inhibitors such as miransertib in combination with mTOR inhibitors serves as a broadly applicable therapeutic in NHL.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Echocardiographic Screening for Postoperative Pericardial Effusion in Children.

Pericardial effusion (PE) after cardiac surgery can be life threatening without timely detection, and the optimal screening method is unknown. We sought to evaluate the role of a surveillance echocardiogram on postoperative day 10 (± 2), determine the incidence of postoperative PE, and identify risk factors. We conducted aretrospective cohort study including all pediatric patients who underwent open heart surgery at a single institution over a 7-month period. To identify risk factors for PE, medical records of patients with PE detected within 6weeks after surgery (cases) were compared with patients without PE (controls). Of 203 patients, 52 (26%) had PE within 6weeks; 42 (81%) were trivial-small and 10 (19%) were moderate-large. Twenty-nine (56%) were first detected within 7days post-operatively, including all cases developing cardiac tamponade (n = 3). An echocardiogram was done 10 (± 2) days post-operatively in 41/52 cases, of which 12/41 (29%) did not have a PE at this time, 24/41 (59%) had a trivial-small PE, and 5/41(12%) had a moderate-large PE; 2 of the latter had no prior detected PE. Closure of an atrial septal defect had the highest incidence of PE (42%). PE cases were associated with postoperative nasopharyngeal detection of a respiratory virus (OR 3.8, p = 0.03). In conclusion, the majority of PEcases were detected within 7days post-operatively, including all cases subsequently developing cardiac tamponade. Day 10 echocardiography infrequently detected a moderate or large effusion that had previously gone undiagnosed. A positive perioperative nasopharyngeal aspirate for a respiratory virus was associated with postoperative PE.

Frequency and Causes of Pericardial Effusion in Patients Presenting to Emergency Department with Dyspnea

Objective: To determine the frequency and causes of pericardial effusion in patients presenting to emergency department with dyspnea. Study Design: Prospective/Observational study Place &amp; Duration:Cardiac Centre, Pakistan Institute of Medical Sciences (PIMS),Islamabad for duration of one year from January 2019 to Dec 2019. Methods: A total 220 patients of both genders with ages above 20 years presented with dyspnea were enrolled in this study. Patients detailed medical history was recorded after taking informed consent. All patients had received echocardiography to examine the incidence of pericardial effusion. Causes of pericardial effusion were recorded. Data was analyzed by SPSS 24.0. Results: Out of 220 patients 38 (17.27%) patients had pericardial effusion. Among these 26 (68.42%) were males while rest 31.58% patients were females. 5 (13.16%) patients had ages &lt;40 years while 33 (86.84%) patients had ages &gt;40 years. 20 (52.63%) patients had small size effusion, 15 (39.47%) patients had moderate size and 3 (7.89%) patients had large size effusion. Neoplastic diseases were the commonest cause of pericardial effusion found in 15 (39.47%) patients followed by idiopathic in 10 (26.32%), uremia in 6 (15.79%) patients, 3 (7.89%) patients had bacterial infections, 3 (7.89%) had HIV positive and 1 (2.63%) patient had other. Conclusion: It is concluded that incidence of pericardial effusion is high in patients with unexplained dyspnea. Neoplastic was the commonest cause of pericardial effusion. Keywords: Pericardial Effusion, Frequency, Causes, Dyspnea. Electrocardiogram

Arthroscopic Excision of Intra-Articular Osteoid Osteoma of the Hip: A Case Series

1) To identify the clinical features of intra-articular osteoid osteoma (OO) of hip, 2) to evaluate the clinical effect of arthroscopic excision for intra-articular OO.3) to summarize the characteristics of revision cases of hip OO and the revision surgery under arthroscopy on these cases. We retrospectively reviewed the data of 25 patients who underwent arthroscopic excision of hip OO. The case series included 10 patients who underwent revision surgery. Lesion location, presenting symptoms, and symptom duration were analyzed; postoperative improvement was assessed using the modified Harris Hip Score (mHHS) and international Hip Outcomes Tool (iHot-12) scores. We examined the reasons for need of revision surgery and the characteristics of OO progression after the first surgery. The most common presenting symptom was groin pain that was relieved by nonsteroidal anti-inflammatory drugs (NSAIDs). Varying degree of limitation of range of motion (ROM) was present in all patients. The osteosclerosis around the tumor nest in CT scan is a characteristic radiographic feature in this disease. However, the classic radiographic feature was only apparent on plain x-rays in 2 out of 25 patients. As a kind of efficient radiological method, MRI can help in distinguishing OO from femoroacetabular impingement (FAI), as the latter is characterized by a large effusion and bone marrow edema at the atypical site of impingement. For the patients who had only one arthroscopic resection, the mean mHHS and iHot-12 scores were 70.30 ± 9.06 (51-86) and 75.07 ± 7.69 (57-88), respectively. At last follow-up, the mean scores were 98.30 ± 2.15 (94-100) and 97.76 ± 2.04 (94-100). respectively (Table 3). For revision cases, the mean mHHS and iHot-12 scores were 68.55 ± 3.77 (60-72) and 67.88 ± 5.39 (56-76), respectively. At last follow-up, the mean scores were 97.11 ± 2.47 (94-100) and 95.22 ± 1.78 (94-100). respectively. In the present study, 24 of 25 patient (96%) reached the MCID of mHHS and 21 of 22 patients (95.2%) reached the MCID of iHot-12. Among the revision patients, the most common misdiagnosis at first surgery was FAI. Another feature is that a wrong diagnosis or incomplete intra-articular OO resection can stimulate the tumor and cause an inflammatory reaction and rapidly progressive OA, necessitating prompt revision surgery for complete removal. The degree of joint degeneration was related to the time since the first operation. OO of the hip joint typically presents with pain and limited joint activity. Misdiagnosis as FAI or synovitis is common and so that patient who has limit ROM, night pain and can be relieved by NASIDs should be suspected OO, and more advanced radiological evaluation, such as CT scan, should be performed. Arthroscopic excision appears to be an effective method for the treatment of OO of the hip joint. IV, case series.

48-Year-Old Woman With Dyspnea and Chest Pain

48-Year-Old Woman With Dyspnea and Chest Pain

Temporary ab interno suture cyclopexy for closing a cyclodialysis cleft during cataract surgery.

Cyclodialysis clefts are often associated with ocular hypotony and attendant maculopathy. However, these clefts create an alternative aqueous outflow pathway that can be useful to maintain intraocular pressure (IOP) at physiologic levels under some conditions. At normal levels of IOP, they might prevent glaucoma damage and avoid maculopathy of hypotony. Indeed, historically, cyclodialysis was a planned surgical method for managing glaucoma, and more recently, a minimally invasive glaucoma surgery device that created a small-stented cyclodialysis was in use until removed from the market for unrelated concerns. Cataract surgery in the presence of a cleft, however, might be complicated by extensive fluid misdirection through the cleft with resultant large suprachoroidal effusion. A technique of ab interno temporary suture cyclopexy was devised for a patient needing cataract surgery with an existing traumatic cyclodialysis cleft that was vital for long-term management of IOP. The suture was used to close the cleft transiently during surgery and was removed at the close of the procedure to reestablish patency and preserve the cleft.

Conservative and surgical modalities in the management of paediatric parapneumonic effusion and empyema: a protocol for a living systematic review and network meta-analysis

IntroductionParapneumonic effusion and empyema are common complications of paediatric pneumonia. Acceptable treatment modalities for large parapneumonic effusions include antibiotics alone or in conjunction with surgical interventions. Clear guidelines on the...

Pericardial effusion uncovering underlying hypothyroidism.

Pericardial effusion may be the tipping point to unravel hypothyroidism. Large effusions may not correlate with severity of cardiovascular compromise. Medical therapy over surgical intervention is appropriate if no evidence of cardiac tamponade.

Contemporary management of pericardial effusion.

Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade. The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. While medical therapy should be offered to patients with elevation of inflammatory markers, in specific forms treatment should be appropriate to the underlying disorder. In cases with hemodynamic compromise pericardial drainage either with pericardiocentesis or pericardial "window" is indicated for therapeutic and diagnostic purposes. In the remainder, factors like comorbidities, size and location of the pericardial effusion will influence the clinical decision making. In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, according to recent evidence, a conservative approach with watchful waiting seems the most reasonable option. The prognosis of pericardial effusions largely depends on the underlying etiologies. Metastatic spread to the pericardium has an ominous prognosis whereas large to moderate effusions have been often associated with known or newly discovered specific underlying causes. Chronic small idiopathic effusions have an excellent prognosis and do not require specific monitoring. Large chronic idiopathic effusions in clinically stable patients require a 3 to 6-month assessment ideally in a specialized unit.

Recurrent cardiac tamponade with stevens–Johnson's syndrome – A rare deadly combo

Pericardial effusion is an accumulation of fluid in the pericardial sac. It is caused by exudative or transudative collections. Large effusions can lead to a life-threatening condition called tamponade if not intervened properly. Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis are life-threatening cutaneous drug reactions in which the epidermis is separated from the dermis. The diagnosis mainly relies on the clinical signs and histopathology of skin lesions. Immunological mechanisms, reactive drug metabolites, or interactions between these two are proposed. Here, we report a case of recurrent cardiac tamponade with SJS secondary to empirical antituberculous therapy.

The impact of comorbidities on diagnosis and treatment of pleural effusions of various origins

Relevance. The incidence comorbidities increases and and types of comorbidities change with the patient’s age. The severity can be assessed using multiple scales. The aim of this study was to identify the specifics of surgical intervention tactics to be used for treatment of pleural effusions of various etiologies, depending on comorbidities. Methods. Comorbid pathology was assessed in 424 patients with pleural effusions of various origins using three indices developed by Charlson, Karnovsky, and the European Joint Oncological Group (ECOG). Thoracentesis, drainage of the pleural cavity, and videothoracoscopy with pleural biopsy were used for diagnosis and treatment. Results. HIV, chronic hepatitis, and diseases of the gastrointestinal tract represented the most common comorbid pathologies in patients below the age of 49; cardiovascular diseases and diabetes mellitus were the most common comorbidities in patients after the age of 50. The Charlson's index was 2.6 ± 2.5 for patients younger than 39, 7.9 ± 2.7 for patients in the age range between 60 and 69, and 9.5 ± 2.5 for patients who were older than 70. 34 patients underwent pleural punctures as treatment of small and medium effusions with the Karnowski index less than 40 % and ECOG of 3 — 4 points; 33 resuscitated patients with more severe pathology underwent pleural cavity drainage due to large effusions without fragmentation. 355 patients underwent video thoracoscopy with pleural biopsy; 135 patients received intraoperative pleurodesis by insufflation of talcum powder, and 19 patients had trichloroacetic acid applied to the pleura. 17 (4%) patients died from worsening of the underlying disease and decompensation, including one case of myocardial infarction. Patients with fatal outcome had the Charlson's index of 9.4 ± 3.9, and survivors — 6.9 ± 3.1. Conclusion . Worsening of main pathology and comorbidities, age over 60, Charlson's comorbidity index higher than 8, and an unfavorable prognosis for pleural effusions of various origins serve as an indication for the most conservative diagnostic and treatment approach.

Effusive-constrictive cholesterol pericarditis: a case report.

BackgroundCholesterol pericarditis (CP) remains a rare pericardial disease characterized by chronic pericardial effusions with high cholesterol concentrations with or without the formation of cholesterol crystals. Effusions are often large and can cause ventricular compression and subsequent pericardial adhesion formation. CP can be idiopathic but has associations with rheumatoid arthritis (RA), tuberculosis and hypothyroidism.Case summaryWe present a case of a 72-year-old male with a background of seropositive RA with a finding of an incidental pericardial effusion on computed tomography thorax abdomen and pelvis. Transthoracic echocardiogram demonstrated a large effusion with echocardiographic features of tamponade. On review, he was breathless with a raised venous pressure, bilateral ankle oedema, and pulsus paradoxus was present. Pericardial drainage was performed with fluid analysis demonstrating a cholesterol concentration of 8.3 mmol/L and numerous cholesterol crystal formation. Interval imaging demonstrated recurrence of the effusion with pericardial thickening and progressive constriction. He remained asymptomatic and underwent a successful pericardial window. At present, he is under close clinical outpatient surveillance with symptoms guiding a future pericardiectomy if warranted.DiscussionCP can present as an emergent situation with signs and symptoms of acute heart failure with prompt pericardiocentesis required in cases of clinical tamponade. However, the disease course is often one of chronicity with relapsing large effusions that tend to recur following drainage, with the development of pericardial constriction necessitating pericardiectomy for definitive management.