Massive Pericardial Effusion Research Articles

Massive pericardial effusion and cardiac tamponade revealed undiagnosed Turner syndrome: a case report

BackgroundPatients with Turner syndrome (TS) are prone to autoimmune disorders. Although most patients with TS are diagnosed at younger ages, delayed diagnosis is not rare.Case presentationA 31-year-old woman was presented with facial edema, chest tightness and dyspnea. She had primary amenorrhea. Physical examination revealed short stature, dry skin and coarse hair. Periorbital edema with puffy eyelids were also noticed with mild goiter. Bilateral cardiac enlargement, distant heart sounds and pulsus paradoxus, in combination with hepatomegaly and jugular venous distention were observed. Her hircus and pubic hair was absent. The development of her breast was at 1st tanner period and gynecological examination revealed infantile vulva. Echocardiography suggested massive pericardial effusion. She was diagnosed with cardiac tamponade based on low systolic pressure, decreased pulse pressure and pulsus paradoxus. Pericardiocentesis was performed. Thyroid function test and thyroid ultrasound indicated Hashimoto’s thyroiditis and severe hypothyroidism. Sex hormone test revealed hypergonadotropin hypogonadism. Further karyotyping revealed a karyotype of 45, X [21]/46, X, i(X) (q10) [29] and she was diagnosed with mosaic + variant type of TS. L-T4 supplement, estrogen therapy, and antiosteoporosis treatment was initiated. Euthyroidism and complete resolution of the pericardial effusion was obtained within 2 months. ConclusionHypothyroidism should be considered in the patients with pericardial effusion. The association between autoimmune thyroid diseases and TS should be kept in mind. Both congenital and acquired cardiovascular diseases should be screened in patients with TS.

Intrapericardial immature teratoma with pericardial effusion in a 4-month-old boy

Abstract Intrapericardial teratoma is an extremely rare mediastinal teratoma that arises at the junction of the ascending aorta and right atrial appendage. The teratoma is often complicated by massive pericardial effusion that compresses the heart and lungs, leading to heart failure and/or respiratory distress and potentially fatal outcomes in early infants. A 4-month-old boy was referred to our institute with slowly progressive appetite loss and respiratory distress and was diagnosed with intrapericardial teratoma with pericardial effusion. The patient underwent simultaneous surgical drainage of the pericardial effusion and tumor resection. The tumor was pathologically diagnosed as an immature teratoma. The postoperative course was uneventful. He is now being followed up in the outpatient clinic and shows no clinical or radiological signs of recurrence.

Mesothelial Cells in Lymph Nodes Associated with Massive Pericardial and Bilateral Pleural Effusion, a Diagnostic Dilemma: Report of a Case

Malignant pleural mesothelioma is a rare neoplasm that mostly occurs in elderly men. Recurrent unilateral pleural effusion is the most typical presentation and it is very rare to find extra-thoracic lymphadenopathy before the primary tumor, even in advanced cases. Herein, we report a challenging case of a young man presenting with unresolved fever, sore throat, and dysphagia associated with massive pleural effusion, cardiac tamponade, and multiple cervical lymphadenopathy with mesothelial cells infiltration.

Incidence and characteristics of acute aortic dissection in patients with out-of-hospital cardiopulmonary arrest evaluated by non-contrast computed tomography.

The exact epidemiology of acute aortic dissection, including cases of out-of-hospital cardiopulmonary arrest, is unclear. We aimed to investigate the incidence and characteristics of acute aortic dissection in patients with out-of-hospital cardiopulmonary arrest transferred to our institution and validate the related factors to out-of-hospital cardiopulmonary arrest in Stanford type A acute aortic dissection. We retrospectively reviewed the acute-phase computed tomography data of patients with out-of-hospital cardiopulmonary arrest who visited our hospital between 1 January 2015 and 31 December 2017. Among 1011 consecutive patients with out-of-hospital cardiopulmonary arrest, excluding those aged 17 years and younger and exogenous out-of-hospital cardiopulmonary arrest, such as suicide and trauma, 934 underwent computed tomography examination and 71 (7.6%) were diagnosed with acute aortic dissection: 66 with Stanford type A and five with type B acute aortic dissection (out-of-hospital cardiopulmonary arrest group). Seventy-five patients without out-of-hospital cardiopulmonary arrest with Stanford type A acute aortic dissection visited our institution during the same period (non-out-of-hospital cardiopulmonary arrest group). Age, incidence of massive bloody pericardial effusion and massive intrathoracic haemorrhage were significantly higher in the out-of-hospital cardiopulmonary arrest than in the non-out-of-hospital cardiopulmonary arrest group (78 ± 8 years, 72.7% and 24.2% vs. 70 ± 13 years, 26.7% and 1.3%, respectively; all P < 0.01). These variables were independently related to out-of-hospital cardiopulmonary arrest. There may be more patients with acute aortic dissection with out-of-hospital cardiopulmonary arrest than previously thought. Aortic rupture into the pericardial space or thoracic cavity is the major cause of out-of-hospital cardiopulmonary arrest in these cases. Non-contrast computed tomography can be used to diagnose acute aortic dissection in patients with out-of-hospital cardiopulmonary arrest. Our study is one of a few to evaluate the real circumstances surrounding acute aortic dissection and its epidemiology.

ANTISYNTHETASE SYNDROME AND PLEURAL EFFUSION: A CASE REPORT

ANTISYNTHETASE SYNDROME AND PLEURAL EFFUSION: A CASE REPORT

Chronic Active Epstein-Barr Virus Infection in a Patient with Enteritis, Myositis, and Pericardial Effusion: A Case Report

Introduction: Chronic active Epstein-Barr virus infection (CAEBV) is a rare, life-threatening disease entity involving multiple organs and systems. The disease could be presented in a single organ with atypical symptoms, be misdiagnosed at the early phase, and resolved without aggressive treatment. Previous studies reported favorable outcomes with early diagnosis and treatment, while in other cases, disease progression and presenting in other organs could result in a very poor outcome. Clinicians from any department should be aware of the CAEBV entity when an unresolved systemic inflammation presents. Case Presentation: A 61-year-old female presented to the cardiology department due to edema and fatigue with the progression of symptoms, including fever, muscle weakness, and shortness of breath. MR images showed muscular edema, and ultrasound analysis revealed massive pericardial effusion. Results of laboratory tests indicated hematological involvement, liver damage, and positivity for EBV DNA, and EBER in muscle and intestine by staining. She was first misdiagnosed with ulcerative colitis, but the disease evolved to the muscles and cardiovascular system later on. Altogether, the CAEBV infection with enteritis, myositis, and pericardial effusion was confirmed in the case. Although diagnosed, the treatment of the elderly population remains rather challenging in severe cases. The patient died after disease onset for less than three years. Conclusions: Elderly patients with CAEBV infection tend to have a poor prognosis. Early diagnosis would facilitate early treatment and the utilization of available options, which might reduce the disease mortality rate eventually. Individualized therapy and promising approaches should be further developed for CAEBV infection.

Primary cardiac hydatid cyst presenting with massive pericardial effusion: a case report

BackgroundCardiac hydatidosis is a rare manifestation of Echinococcus infection. It represents 0.5 to 2% of hydatic disease (Mustafa et al., Can J Cardiol 22:2, 2006). The most common localization is the myocardium of the left ventricle but can also touch the right ventricle, atrium, pericardium, interventricular septum, and pulmonary artery. Clinical presentation is varied ranging from clinical latency or minor symptoms to cardiogenic shock and sudden death. The present case describes a primary pericardial hydatid cyst, a very exceptional localization of cardiac hydatidosis, which can lead to a delayed diagnosis or to an erroneous treatment that can expose the life of the patient to complications and death if it is not considered. Diagnosis can be established by cardiac imaging and hydatid serology. Therapy management should combine both surgery and medical treatment by albendazole or mebendazole.Case presentationWe report a 70-year-old woman from Sale, who was admitted for dyspnea New York Heart Association (NYHA) class IV evolving in a febrile context with signs of right heart failure related to a rupture of a primary pericardial hydatid cyst with pre-tamponade. The diagnosis was confirmed by echocardiography, computed tomography scan (CT scan), and hydatic serology, and the patient was operated and put on albendazole for 3 months with favorable clinical course.ConclusionsThe aims of this article are to consider the diagnosis of cardiac hydatid cysts in the presence of pericardial effusion, especially if there is a prior history of hydatid disease, a contact with animals, or when it occurs in an endemic country, and to be able to make a differential diagnosis with cardiac imaging in order to avoid its complications and to guide the management.

Purulent Pericarditis with Cardiac Tamponade Secondary to Candida Albicans after Total Parenteral Nutrition: A Case Report

Purulent pericarditis is characterized by a purulent pericardial fluid, which usually originates from the extension of a nearby bacterial infection site or by blood dissemination. Candida species is a rare cause of pericarditis; and if not treated, it is extremely fatal. In this report, we describe a 54-year-old man who had esophagojejunostomy due to gastric adenocancer 2 months before his admission into our emergency department with dyspnea, orthopnea, chest pain, and somnolence. Physical and echocardiographic examinations revealed massive fibrinous pericardial effusion, causing pericardial tamponade. We performed urgent pericardiocentesis. The culture of the purulent pericardial fluid illustrated Candida albicans. There was no gastropericardial fistula after endoscopic and computed tomographic evaluations of the gastrointestinal tract. After receiving 1 month of antimicrobial treatment, the patient recovered completely. During his follow-up, he remained asymptomatic and had no pericardial fluid for 6 months. Our case indicates the possibility of the occurrence of purulent pericarditis with tamponade, secondary to the dissemination of Candida albicans from total parenteral nutrition after gastric carcinoma surgery without gastropericardial fistulae or anastomosis leak.

A massive pericardial effusion in South Africa is not always due to tuberculosis

South Africa (SA) has a high incidence of tuberculosis. Medical conditions mimicking tuberculosis often result in erroneous treatment with antitubercular therapy (ATT) before a definitive diagnosis is made. We report on 2 cases presenting with massive pericardial effusions secondary to Still’s disease (sJIA) and Adult onset Still’s disease (AOSD). Both cases were treated with ATT, with an alternative diagnosis only considered upon poor response to therapy and the development of ATT associated side effects. Our objective is to remind clinicians of other potential differential diagnoses in the clinical scenario of massive effusive pericarditis in a tuberculosis endemic region.

SAT-499 Myxedema Coma Presenting as Large Pericardial Effusion with Cardiac Tamponade

BackgroundMyxedema coma is a life-threatening decompensated form of hypothyroidism. Current treatment recommendation is intravenous levothyroxine. However, in areas where parenteral form of levothyroxine is unavailable, levothyroxine tablet is the only option.Clinical CaseA 48-year old male known to have chronic glomerulonephritis and hypertension, came in due to lacerated scalp wound sustained after falling asleep. Pertinent laboratory exams showed mild anemia, hemoglobin 10.6 g/dL (reference range 13–17) and hyponatremia 128mmol/L (reference range 136–145). His estimated creatinine clearance was 60mL/min. Cranial CT scan showed no signs of acute hemorrhage or fracture. There was scalp swelling and laceration with subgaleal hematoma over the frontal region. Electrocardiogram showed low voltage complexes. Chest radiograph showed an enlarged cardiac silhouette suggesting pericardial effusion. Transthoracic echocardiography was requested revealing a massive pericardial effusion with tamponade physiology. Patient underwent emergency pericardial window with pericardiostomy tube placement, debridement and suturing of scalp laceration under general anesthesia. He was able to tolerate the procedure well but noted to have decreased sensorium post-operatively. ABG revealed respiratory acidosis with pH 6.9 and incalculable pCO2. He was subsequently intubated. Further laboratory investigations showed undetected FT4 0.0ng/dL (reference range 0.58–1.64) and elevated TSH 23.87µIU/mL (reference range 0.38–5.33). Anti-TPO was elevated 333 µIU/ml (reference range 0–35). He was started on hydrocortisone followed by levothyroxine 200 µg tablet through NGT daily. His condition improved after few days and was weaned off from mechanical ventilator. Repeat echocardiogram showed resolution of previously noted massive pericardial effusion with preserved systolic and diastolic functions. He was eventually discharged after a month on levothyroxine. Follow-up after 1 month, patient was clinically stable with normal thyrotropin level at 0.67µIU/mL.ConclusionMyxedema coma is a life threatening form of hypothyroidism and may be difficult to recognize initially especially in patients with pre-existing kidney disease due to overlap in clinical findings. Treatment with levothyroxine administered enterally is possible especially if the intravenous form is unavailable.

SUN-697 Importance of Immunosuppressive Therapy for Managing Insulin Resistance Type B

Background: Autoimmune Antibodies against insulin receptors leading to refractory hyperglycemia is known as Type B insulin resistance. In addition to insulin management, immunosuppressive therapy appears to be an essential part for successful management. Clinical Case: A 20 year old African American woman with no significant past medical history presented to the Emergency Department with worsening nausea and vomiting for 5 days and shortness of breath. She admitted to polyuria, unintentional weight loss of 15 pounds in the last six months, decreased appetite, and hyper-pigmented rashes mostly on her back. The patient was not on any medications at home. No known drug allergies, no past surgical history. Family history was significant for Grandmother with Type 2 Diabetes Mellitus and Lupus on father’s side of family. The patient denied use of alcohol, tobacco, illicit and IV drug use. T: 37.2 °C, HR: 124, RR: 25, BP: 105/74, SpO2: 100%. Weight 45kg. Physical exam significant for Tachycardia but normal rhythm. Initial work up revealed new onset diabetes HbA1c 9.6% and massive pericardial effusion on echocardiogram s/p pericardiocentesis. Due to developing complaints of intermittent cyanosis of fingertips and intermittent joint pain of fingers, Rheumatology work up was ordered and positive for mixed connective tissue disease. Patient was treated with Cellcept 1500 mg BID, Plaquenil Sulfate 300 mg daily, and prednisone 12.5 mg BID. Hospital course was complicated due to hyperglycemia in 300s-400mg/dL requiring high amounts of insulin. Diabetes work up was negative for GAd-65 and islet cell antibodies. C-peptide was elevated at 16.1 ng/mL (0.8-3.1 ng/mL) and anti-Insulin an antibodies was 20uU/mL. Patient was euthyroid. Hyperglycemia persisted despite increasing doses of long and short acting insulin subcutaneously. The patient eventually required Insulin intravenously at 50 units/hour plus 50 units of short acting Insulin every 4 hours subcutaneously. The patient was transferred to a facility to begin Combined Immunosuppressive Therapy plus insulin to manage hyperglycemia due to insulin resistance. After six months of rituximab, high-dose pulsed steroids, cyclophosphamide, plus insulin therapy, glycemic index improved with HbA1c reduced to 5.6%. Conclusion: Combined Immunosuppressive Therapy in addition to insulin management of refractory hyperglycemia due to type B insulin resistance has been shown to not only be effective in controlling refractory hyperglycemia but preventing against recurrences as well. Reference: 1) Klubo-Gwiezdzinska J, Lange M, Cochran E, Semple RK, Gewert C, Brown RJ, Gorden P. Combined Immunosuppressive Therapy Induces Remission in Patients With Severe Type B Insulin Resistance: A Prospective Cohort Study. Diabetes Care. 2018 Nov;41(11):2353-2360.

SAT-458 A Case of Cardiac Arrest Due to Hashimoto’s Thyroiditis Associated Cardiac Tamponade

Introduction: Myxedema coma is currently an uncommon medical emergency. We present a case of undiagnosed Hashimoto’s thyroiditis with myxedema coma and cardiac tamponade leading to cardiac arrest. Case Presentation: A 35 year-old man with no significant past medical history was brought to the emergency department after being found unresponsive. The patient was hypoglycemic (17 mg/dL), hypothermic (34°C), tachypneic (26/min), hypotensive (84/50 mmHg), and hypoxemic (90% on ambient air). Physical exam showed mild anasarca, jugular vein distention, clear lung sounds, and muffled heart sounds. Laboratory findings showed TSH 168.16 uIU/mL (0.45–5.33 uIU/mL), fT4 <0.25 ng/dL (0.58–1.64 ng/dL), fT3 1.33 pg/mL (2.5–3.9 pg/mL), cortisol 5.7 mcg/dL (3–16 mcg/dL). Chest x-ray demonstrated markedly enlarged, globular heart. ECG revealed sinus rhythm and low voltage of QRS complexes. Echocardiogram was significant for a very large pericardial effusion. Resuscitation was started with intravenous thyroxine and hydrocortisone, during which the patient was found to be in a cardiac arrest with pulseless electrical activity. CPR per ACLS protocol was initiated with return of spontaneous circulation. Clear fluid (2000 ml) was evacuated from the pericardial space. He was diagnosed with Hashimoto thyroiditis (thyroid peroxidase antibody level 355 IU/mL, normal <9 IU/mL). He recovered without neurological deficits and was discharged home with thyroid replacement therapy (levothyroxine 100 mcg). Discussion: Myxedema coma occurs as a complication of undiagnosed/untreated thyroid disease. It may be precipitated by an event such as infection, drug overdose, or myocardial infarction. The mainstay of treatment is T4 replacement along with supportive therapy, and glucocorticoids to counter possible underlying adrenal insufficiency. Massive pericardial effusion due to hypothyroidism, especially resulting in cardiac tamponade, is extremely rare. The incidence of pericardial effusion in patients with hypothyroidism has significantly decreased from 30–80% to 3–6%, due to early recognition of this common disorder. Our case highlights the importance of prompt recognition of hypothyroidism as a cause of cardiac tamponade, thus allowing rapid life-saving treatment. In patient populations with limited access to health care, it should be remembered that very late and potentially fatal complications of otherwise easily treatable conditions can occur. Awareness of this may help limit morbidity and mortality.

SAT-484 Presyncope as Initial Presentation of Massive Pericardial Effusion with Tamponade in a Patient with Primary Hypothyroidism

Presyncope as initial presentation of massive pericardial effusion with tamponade in a patient with primary hypothyroidism Background: Hypothyroidism is an endocrinologic disorder that affects multiple systems ranging from cardiovascular, central nervous system, musculoskeletal, etc. One of the possible cardiovascular complications of hypothyroidism is pericardial effusion which is only rarely associated with tamponade. In this case report we have a 49 years old woman who presented with impending pericardial tamponade secondary to chronic primary hypothyroidism. Clinical case: A 49 years old woman with history of hypothyroidism presented to the hospital on account of headache, dizziness with presyncope episode, generalized weakness and shortness of breath for 7 days, physical exam showed normal vital signs, distant heart sounds, laboratory tests showed TSH:29.5 uIU/mL (normal range 0.270- 0.4200 uIU/mL), fT4: <0.1ng/dL (normal range 0.9–1.8 ng/dL), fT3: 1.68 pg/mL (normal range 1.80–4.60 pg/mL. Electrocardiogram showed low voltage QRS, chest CT showed large pericardial effusion with findings suggestive of right heart failure, Echocardiogram showed left ventricular dysfunction and large pericardial effusion. The patient was taken to the operating room for emergent pericardial window creation with pericardiectomy and was admitted to the Cardiac Care Unit for management of tamponade status post pericardial window. Levothyroxine 150 mcg, Liothyronine 25 mcg and Hydrocortisone 50 mg were started, the steroid was discontinued after adrenal insufficiency was ruled out. The pericardial drain was removed after 8 days and repeated tests showed TSH: 13.1 uIU/mL, fT3: 3.37 pg/mL, fT4: 0.5 ng/dL, studies of pericardial fluid only showed polymorphonuclear cells. The patient’s symptoms resolved and she was discharged on Levothyroxine 150 mcg and Liothyronine 25 mcg. During follow up visits the thyroid function tests were normal, Liothyronine was discontinued and a repeated Echocardiogram showed normal systolic function. Conclusions: Pericardial effusion can be found in 3–30% of patients with hypothyroidism but only in very rare cases (less than 3%) is associated with cardiac tamponade and occurs when there is a severe underlying condition like myxedema coma or prolonged untreated hypothyroidism (1). It is important not to miss that dizziness and presyncope in a patient with hypothyroidism may be a manifestation of cardiac tamponade. Once the diagnosis of hypothyroidism is made it is imperative to start treatment early as untreated hypothyroidism can cause severe cardiovascular complications but even when such are present, they can be reversible with thyroid replacement therapy. Reference: (1) Kahaly, G. and Dillmann, W. (2005). Thyroid Hormone Action in the Heart. Available at: https://academic.oup.com/edrv/article/26/5/704/2355198 [Accessed July 12 2019].

Primary Cardiac Diffuse Large B-cell Lymphoma Promptly and Safely Diagnosed with Pericardial Effusion Cytology

Primary cardiac lymphoma is a rare condition with a poor prognosis, and patients are at risk for sudden cardiac death. A prompt diagnosis and early treatment are therefore essential. A 68-year-old woman was admitted for shortness of breath and peripheral edema. Echocardiograms showed massive pericardial effusion and a mass on the free wall of the right atrium and ventricle. Subsequent pericardial effusion cytology revealed diffuse large B-cell lymphoma. We started chemotherapy with rituximab and achieved a good clinical course. This case is made unique by the use of pericardial effusion cytology, which allowed us to diagnose primary cardiac lymphoma promptly and safely.

A Rare Case of Pericardial Decompression Syndrome in a Filipino Female Patient With Suspected Malignant Pericardial Effusion

Pericardial decompression syndrome (PDS) is a rare, under-reported and potentially fatal complication of pericardial drainage characterized by paradoxical hemodynamic deterioration. The onset ranges from immediate to as long as 48 h post drainage. We present a case of a 51-year-old woman admitted due to progressive dyspnea. She was hemodynamically stable but with signs of cardiac tamponade. On two-dimensional echocardiography (2D-echo) there was a massive pericardial effusion in tamponade physiology. Immediate surgical drainage was done but intra-operatively there was depressed cardiac contractility necessitating inotropic support. Post-operative 2D-echo showed right ventricular (RV) and left ventricular (LV) systolic dysfunction. She was admitted in the intensive care unit (ICU) for 72 h. Repeat 2D-echo showed marked improvement in RV and LV systolic function. She was then discharged improved on the fifth hospital day. The pathophysiology of PDS is still not very clear. The simplest mechanism is that sudden removal of compressing pericardial fluid causes increased venous return with expansion of the RV at the expense of the LV leading to acute heart failure. There are no published studies to propose preventive measures and treatment remains supportive. There has been only one published case reported here in our country. We report this case of a patient who successfully recovered from PDS. J Med Cases. 2020;11(4):86-89 doi: https://doi.org/10.14740/jmc3446

New Onset Systemic Lupus Erythematosus Presenting with Massive Pericardial Effusion: A Case Report

Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disorder with multiple system involvements whichcommonly affects the cardiovascular system. Although pericarditis and pericardial effusion are prevalent cardiac manifestationsin SLE, massive pericardial effusion as an initial presentation is unusual. We describe a 47-year-old woman who presented tothe hospital with a headache, dry cough, shortness of breath, and fatigue. According to the clinical, radiologic, echocardiographicand laboratory rheumatologic test findings, SLE was diagnosed and treatment with prednisolone, hydroxychloroquine, andmycophenolate mofetil was initiated. The patient improved clinically, and follow-up echocardiography showed a reduction inthe effusion volume compared with previous tests within the preceding 6 months. In patients with cardiopulmonary symptoms,especially when other organ involvement is seen, screening for autoimmune systemic diseases such as SLE should beconsidered. To achieve rapid recovery and prevent life-threatening complications, early diagnosis and treatment are essential.

Case report of a submandibular abscess lethally tracking down through the mediastinum presenting as cardiac empyema

A 46-year-old male presented to our emergency with sudden severe shortness of breath and was found to have massive pericardial effusion causing cardiac tamponade and atrial fibrillation. He had to undergo immediate pericardiocentesis to relieve his symptoms and it drained frank pus indicating pericardial empyema as the underline cause of tamponade. On physical examination, patient was found to have a left submandibular tender swelling. He had increased inflammatory markers and on further imaging the CT showed massive diffuse mediastinal abscess. The patient had to undergo urgent surgery by multiple specialist surgeons in which large amount of pus was drained from the submandibular and mediastinum resulting in improvement of his condition and speeded his recovery. Key Messages • Thorough history and examination are of utmost importance. • Immediate treatment of pericardial tamponade is lifesaving. • High index of suspicion of descending mediastinitis should arise whenever purulent pericardial drainage is encountered. • Early diagnosis of mediastinal abscess by doing early radiographic investigations reduce mortality. • Head and neck abscesses must be treated properly to prevent life-threatening conditions.

Pericardial Effusion as an Initial Presentation of Panhypopituitarism.

Pericardial effusion has a broad spectrum of clinical presentation, ranging from an incidental finding on imaging to a potentially fatal emergency such as pericardial tamponade, the most severe presentation. The authors present a case of a middle-aged male hospitalized due to shortness of breath. Initial work-up was positive for massive pericardial effusion with haemodynamic compromise. Additional study revealed panhypopituitarism. The acromegalic phenotype was suggestive of acromegaly secondary to pituitary adenoma, which had probably evolved to apoplexy. Hormone replacement was started with clinical improvement. At the 3-year follow-up, there was no evidence of recurrence of pericardial effusion. Panhypopituitarism is a relatively rare entity, but can lead to life-threatening complications such as adrenal crisis, coma and myxoedema-associated cardiac failure. Pericardial effusion is an extremely rare manifestation of secondary hypothyroidism.LEARNING POINTSTo recognize the clinical presentation of cardiac tamponade.To recognize atypical causes of pericardial effusion, such as severe panhypopituitarism.Hormonal replacement is efficient in treating panhypopituitarism.

Etiology of Pericardial Effusion and Outcomes Post Pericardiocentesis in the Western Region of Saudi Arabia: A Single-center Experience.

BackgroundPericardial effusion is the accumulation of blood or excess fluid in the cavity between the heart and the pericardium sac. Pericardial effusion can be caused by several etiologies, including malignant and non-malignant causes. Pericardiocentesis is the gold standard assessment method for pericardial effusion etiology. The aim of this study was to identify the long-term outcome of patients who presented with massive pericardial effusion and underwent pericardiocentesis at King Abdulaziz Medical City, Jeddah, a large tertiary hospital in the western part of Saudi Arabia.MethodsThis is a single-center retrospective cross-sectional study conducted at King Abdulaziz Medical City Jeddah, Saudi Arabia, between January 2013 to December 2018. Data were collected from patient’s charts; the clinical and echocardiographic findings, alongside with pericardial fluid analysis, were collected. Procedure and patients outcomes were obtained and reported.ResultsOf the 107 patients with pericardial effusion, 39 patients had moderate to severe pericardial effusion requiring pericardiocentesis. The mean age was 52 years, and 56.4% were females. The most common chronic disease was hypertension and the presence of metastasis. The most common cause of pericardial effusion was a malignancy. A majority of patients had severe pericardial effusion. Many patients had tamponade (69.6%). Patients with malignant pericardial effusion had a median survival of 54 days.ConclusionEtiologies of pericardial effusion requiring drainage depend on the population studied. Patients with malignant effusions have worse outcomes than non-malignant effusion. Pericardiocentesis is required to ascertain the cause and risk-stratify patients.

Fast growing angiosarcoma of the right atrium after radiofrequency catheter ablation: a missed diagnosis or misdiagnosis case report

BackgroundPrimary angiosarcomas of the right atrium are extremely rare, often resulted in missed diagnosis or misdiagnosis with routine examination tools. These malignant cardiac tumors are highly aggressive with generally poor prognosis. Surgical excision is the mainstay of treatment as it is essentially not responsive to current regimens of chemoradiotherapy.Case presentationHerein, we describe a patient who initially presented with paroxysmal atrial fibrillation and was subsequently treated with radiofrequency catheter ablation (RFCA). Prior to RFCA, an initial transesophageal echocardiography revealed a local thickening of the intratrial septum. Three months later, she was hospitalized with progressive dyspnea and massive pericardial effusion. A large immobile, non-pedunculated mass, occupying almost half of the right atrium was detected by transthoracic and transesophageal echocardiogram. Multimodality cardiac imaging was useful in further characterizing this mass, which was ultimately diagnosed as an angiosarcoma based upon biopsy results. The growth rate was extremely rapid following RFCA, and patient underwent surgical excision. After discharge, the angiosarcoma recurred and patient survived for 7 months from the first episode of tamponade.ConclusionsPrimary cardiac angiosarcoma of the right atrium can easily be mistaken for structural anomalies in its early stages, losing the opportunity for initiating earlier treatments to improve potential patient outcomes. The correct diagnosis of this rare case relied on the comprehensive utilization of multimodal imaging techniques including biopsy.