Moderate Pericardial Effusion Research Articles

CLINICAL CHALLENGE: AORTITIS IN THE EMERGENCY DEPARTMENT

Abstract A 67 yo woman presented to the ED for a sustained episode of palpitations and acute chest pain. Past medical history: suspected psoriatic arthritis previously treated with steroids and hydroxychloroquine; previous suspicion of rheumatic polymyalgia and Horton arteritis, regressed with steroids; gastroesophageal reflux disease; mild hypercholesterolemia and a family history of premature coronary artery disease. In the ED the patient was hemodynamically stable. On physical examination: tachyarrhythmic heart sounds with no murmurs. The peripheral arterial pulses were preserved and symmetrical. The remaining physical examination was unremarkable. ECG: atrial fibrillation at 150 bpm. The D–dimer was increased, normal hs–troponin and normal haemoglobin. On echocardiography: normal biventricular structure and function; normal aortic root with dilatation of proximal ascending aorta (47 mm), without visible intimal flaps. The anterior wall of the proximal ascending aorta was thickened. A moderate circumferential pericardial effusion was present, without signs of hemodynamic impact. On suspicion of an acute aortic syndrome with possible intramural haematoma of an ascending aortic aneurism, an urgent CT scan was ordered. It showed a severe dilatation of ascending aorta (52 mm) involving of the proximal aortic arch. The anterior aortic wall was thickened (5 mm), without clear images of IMH, aortic dissection or penetrating ulcer. The pericardial effusion had a supra–fluid density without blood density. A repeated CT at 6 hours showed no changes. The case was suggestive of an inflammatory aetiology. The patient was admitted to the cardiac intensive care unit. A PET–CT scan showed signs of an inflammatory disease of the great vessels. A serological autoimmunity screening was negative. The patient was diagnosed with inflammatory aortitis (giant cell vs Takayasu arteritis) and started on high dose iv glucocorticoid therapy. Given the high risk of severe aortic complications, adjunctive therapy with tocilizumab was prescribed. The therapy was gradually tapered, with subsequent switch to oral steroids plus tocilizumab. At one and a half month of follow–up, a CT scan was repeated, documenting stable aortic diameters and the disappearance of the abnormal thickness and of the enhancement of the aortic wall. A follow–up PET–CT scan has been scheduled at 6 months time. An elective aortic intervention has been indicated after remission of the inflammatory phase.

A CASE OF CHRONIC PERICARDITIS IN A YOUNG PATIENT

Abstract A 25–year–old woman was admitted to our department with a diagnosis of pericarditis and pericardial effusion. She reported a flu episode 5 months earlier followed by persistent dry cough, dyspnoea on exertion and palpitations. Due to the persistence of symptoms, she consulted a cardiologist and it was observed a mild to moderate pericardial effusion with a raised C reactive protein at lab test. At first she was treated with ibuprofen and colchicine. After 2 months, prednisone was added to the therapy for effusion worsening. During steroids descalation she started complaining of night fever. Few weeks later an echocardiogram revealed increased pericardial effusion (21 mm) with signs of right atrial compression, so she was admitted to our department. No cardiovascular risk factors were reported but overweight and smoking habit. ECG at admission showed a slight depression of PR in inferior leads. Given the history, persistence of elevated inflammatory markers and fever on admission, despite prolonged therapy with NSAIDs, the patient was treated for high–risk pericarditis, with ibuprofen and colchicine. In addition, aetiological research was pursued: autoantibody and viral panel were negative; chest X–ray showed mediastinal enlargement and swelling in the right hilar region. So an urgent chest CT scan was performed and it showed a 8x9 cm mediastinal mass extending to the pectoral muscles and sternum. The mass biopsy revealed a classical Hodgkin lymphoma so she was transferred to Hematology department and chemotherapy was started. During her hospital stay, the effusion remained stable (17 mm). This clinical case demonstrates that pericarditis, even in a young patient, with a lack of response to NSAIDs therapy and with an unremitting course, must raise the suspicion of an occult cancer. In fact, according to the latest guidelines, in case of high–risk pericarditis, i.e. in the presence of at least one negative prognostic predictor between fever higher than 38°C, subacute onset, severe pericardial effusion, tamponade or failure of medical therapy after one week, aetiological research is indicated, in addition to hospitalization. It shouldn‘t be forgotten that pericarditis may be the first manifestation of an occult extracardiac tumor. In particular, the primary tumors associated with pericarditis are breast cancer, lung cancer and lymphomas. Probably better case management would have allowed an earlier diagnosis and treatment of our patient‘s cancer.

Purulent pericarditis caused by methicillin-sensitive Staphylococcus aureus bacteriuria

BackgroundPurulent pericarditis (PP)— a purulent infection involving the pericardial space—requires a high index of suspicion for diagnosis as it often lacks characteristic signs of pericarditis and carries a mortality rate as high as 40% even with treatment. Common risk factors include immunosuppression, diabetes mellitus, thoracic surgery, malignancy, and uremia. Most reported cases of PP occur in individuals with predisposing risk factors, such as immunosuppression, and result from more commonly observed preceding infections, such as pneumonia, osteomyelitis, and meningitis. We report a case of PP due to asymptomatic bacteriuria in a previously immunocompetent individual on a short course of high-dose steroids.Case presentationAn 81-year-old male presented for severe epigastric pain that worsened with inspiration. He had been on high-dose prednisone for presumed inflammatory hip pain. History was notable for urinary retention requiring intermittent self-catheterization and asymptomatic bacteriuria and urinary tract infections due to methicillin-sensitive Staphylococcus aureus (MSSA). During the index admission he was found to have a moderate pericardial effusion. Pericardial fluid cultures grew MSSA that had an identical antibiogram to that of the urine cultures. A diagnosis of purulent pericarditis was made.ConclusionPP requires a high index of suspicion, especially in hosts with atypical risk factors. This is the second case of PP occurring as a result of asymptomatic MSSA bacteriuria. Through reporting this case we hope to highlight the importance of early recognition of PP and the clinical implications of asymptomatic MSSA bacteriuria in the setting of urinary instrumentation and steroid use.

The impact of the COVID-19 pandemic on cardiovascular disease in the cardiovascular center of Kermanshah, in the west of Iran

BackgroundCardiovascular diseases (CVD) are known as the most common cause of mortality worldwide. Hence, exploring the impact of COVID-19 pandemic on CVD and its risk factors. This study aimed to explore clinical and echocardiographic characteristics and cardiac manifestations in COVID-19 patients. MethodsThis cross-sectional study was conducted on 386 patients with COVID-19 admitted to Imam Ali Hospital, the largest specialized cardiology hospital in western Iran. The checklist included information about age, gender, hypertension, BMI, diabetes, chronic renal disease, cigarette smoking, echocardiography and ECG findings, in-hospital MACE, venous and arterial thrombotic events. To analyze the data, SPSS23, paired-samples t-test, chi-square test and logistic regression analysis were used. ResultsOur findings showed 57 % of patients were male and 43 % were female. The paients' average age was 64.61 ± 14.21 years. Moreover, 25.9 % of patients had diabetes, 27.7 % had blood pressure, 11.7 % were cigarette smokers and 11.1 % had hyperlipidemia. The main electrocardiographic abnormalities were ST-T changes in 1.31 % of the patients, sinus tachycardia in 16.3 % and atrial fibrillation in 11.1 % of patients. Mild to moderate pericardial effusion was observed in 8.1 % and pleural effusion in 9.1 % of the sample. Common cardiac complications were ACS in 52.9 %, DHF in 24.4 %, and CHB in 4.4 % of patients. 19.4 % of patients died during hospitalization. Mild to moderate pericardial effusion (OR = 1.96, 95 % CI 1.18–2.14, P = 0.012) was an independent predictor of mortality in COVID-19 patients. ConclusionResults of the study showed it is essential to pay closer attention to elderly, diabetic and hypertensive patients, who are more prone to COVID-19 infection. Moreover, common cardiac complications were ACS and DHF, respectively.

Shorter antitubercular therapy for extrapulmonary tuberculosis - a case report

IntroductionExtrapulmonary tuberculosis (EPTB) adds to India’s significant economic burden, with pericardial effusion being a potentially fatal complication. This case report highlights the need for early diagnosis and the feasibility of shorter-duration treatment for EPTB in developing countries.PresentationThis case report describes a 19-year-old male from Southeast Asia who had a history of bronchiectasis involving the left lower lobe and the right middle lobe, which was cystic in nature, as well as multiple episodes of non-tuberculous pneumonia. Currently, he presented with fever, hypotension, tachycardia, and acute kidney injury. Echocardiogram showed left ventricular dysfunction with a left ventricular ejection fraction (LVEF) of 45% and moderate pericardial effusion. Early signs of cardiac tamponade were noted, specifically the absence of respiratory variation in the right ventricle and left ventricle collapse. Emergent pericardiocentesis was performed, and hemorrhagic pericardial fluid was aspirated. Fluid analysis revealed high levels of LDH (5000 U/L), polymorphonuclear leukocytosis, and acid-fast bacilli that were visualized on microscopy, which led to the diagnosis of pericardial tuberculosis. A CT of the abdomen showed hepatosplenomegaly and polyserositis. Empirically, antitubercular therapy consisting of isoniazid, rifampin, pyrazinamide, and ethambutol was administered for 2 months and isoniazid along with rifampicin was given for the next 4 months. Serial echocardiograms in the following months showed an improvement in LVEF (55%) and decreased effusion. However, during this treatment period, due to frequent episodes of pneumonia, the evaluation of immunodeficiency disorders was performed and revealed low levels of IgG (4.741 g/L), IgA (0.238 g/L), and IgM (0.098 g/L). He was diagnosed with common variable immunodeficiency disease and received intravenous immunoglobulin therapy.ConclusionThis report emphasizes the timely identification of cardiac tamponade and the effective management of EPTB through a shorter-than-recommended course of antitubercular therapy, resulting in the alleviation of symptoms and better overall health outcomes.

Pericardial effusion in children at tertiary national referral hospital, Addis Ababa, Ethiopia: a 7-year institution based review

BackgroundPericardial effusion (PE) is a rare yet an important cause of child mortality due to collection of excess fluid in pericardial space. The study aimed to describe the PE profile in the national cardiac referral hospital, Addis Ababa, Ethiopia.MethodsThe study employed cross-sectional study design for a 7-year review of childhood PE in Tikur Anbessa Specialized Hospital. Descriptive and analytic statistics were applied.ResultsThere were 17,386 pediatric emergency/ER admissions during the study period, and PE contributed to 0.47% of ER admissions. From 71 included subjects, 59% (42) were males with mean age of 7.8 ± 3.3 years. Cough or shortness of breath,73.2% (52) and fever or fast breathing, 26.7% (19), were the common presenting symptoms. The median duration of an illness before presentation was 14days (IQR: 8–20). The etiologies for pericardial effusion were infective (culture positive–23.9%, culture negative–43.6%, tuberculous-4.2%), hypothyroidism (4.2%), inflammatory (12.7%), malignancy (7%) or secondary to chronic kidney disease (1. 4%). Staphylococcus aureus was the most common isolated bacteria on blood culture, 12.7% (9) while the rest were pseudomonas, 7% (5) and klebsiella, 4.2% (3). Mild, moderate and severe pericardial effusion was documented in 22.5% (16), 46.5% (33), and 31% (22) of study subjects, respectively. Pericardial tamponade was reported in 50.7% (36) of subjects. Pericardial drainage procedure (pericardiocentesis, window or pericardiotomy) was performed for 52.1% (37) PE cases. The case fatality of PE was 12.7% (9). Pericardial drainage procedure was inversely related to mortality, adjusted odds ratio 0.11(0.01–0.99), p 0.049).ConclusionPE contributed to 0.47% of ER admissions. The commonest PE presentation was respiratory symptoms of around two weeks duration. Purulent pericarditis of staphylococcal etiology was the commonest cause of PE and the case fatality rate was 12.7%. Pericardial drainage procedures contributed to reduction in mortality. All PE cases should be assessed for pericardial drainage procedure to avoid mortality.

Detection and molecular analysis of Pseudorabies virus from free-ranging Italian wolves (Canis lupus italicus) in Italy - a case report

BackgroundThe only natural hosts of Pseudorabies virus (PRV) are members of the family Suidae (Sus scrofa scrofa). In mammals, the infection is usually fatal and typically causes serious neurologic disease. This study describes four Aujeszky’s disease cases in free-ranging Italian wolves (Canis lupus italicus). In Italy, the wolf is a strictly protected species and is in demographic expansion.Case presentationThree wolves (Wolf A, B, and C) were found in a regional park in Northern Italy, and one (Wolf D) was found in Central Italy. Wolf A and D were alive at the time of the finding and exhibited a fatal infection with epileptic seizures and dyspnoea, dying after a few hours. Wolf B presented scratching lesions under the chin and a detachment of the right earlobe, whilst Wolf C was partially eaten.The wolves showed hepatic congestion, diffuse enteritis, moderate pericardial effusion, severe bilateral pneumonia, and diffuse hyperaemia in the brain. The diagnostic examinations included virological analyses and detection of toxic molecules able to cause serious neurological signs.All four wolves tested positive for pseudorabies virus (PrV). The analysed sequences were placed in Italian clade 1, which is divided into two subclades, “a” and “b”. The sequences of Wolf A, B, and C were closely related to other Italian sequences in the subclade b, originally obtained from wild boars and hunting dogs. The sequence from Wolf D was located within the same clade and was closely related to the French hunting dog sequences belonging to group 4.ConclusionResults showed the presence of PrV strains currently circulating in wild boars and free-ranging Italian wolves. The genetic characterisation of the PrV UL44 sequences from the four wolves confirmed the close relationship with the sequences from wild boars and hunting dogs. This fact supports a possible epidemiological link with the high PrV presence in wild boars and the possibility of infection in wolves through consumption of infected wild boar carcasses or indirect transmission. To the best of our knowledge, this study is the first detection of Pseudorabies virus in free-ranging Italian wolves in northern and central Italy.

Epidemiological characteristics, etiological spectrum, and outcomes of adult patients with pericardial effusion at a Teaching Hospital in Somalia.

Pericardial effusion (PE) is an abnormal fluid volume in the pericardial space and is a common clinical entity. The incidence of PE is estimated diversely and depends on risk factors, etiologies, and geographic locations. This study aimed to assess the clinical characteristics, etiologic spectrum, echocardiographic features, and outcomes among patients with different types of PE. This retrospective observational study included 93 patients with confirmed PE. Their medical records were reviewed in the hospital information system of Mogadishu Somali Turkish Training and Research Hospital between April 2022 and September 2022. Patient demographics, clinical characteristics, chest X-rays, echocardiography, laboratory findings, management approaches, and outcome reports were reviewed and recorded. Out of the 3000 participants, 3.1% (n = 93/3000) met the definition of definitive PE. In this study, we included 51 females and 42 males. Among the patients, 86% (n = 80) had at least one comorbidity, with diabetes (38.7%) and hypertension (37.6%) being the most common. The most frequently reported clinical presentation findings were shortness of breath (67.7%), chest pain (49.4%), cough (47.3%), and palpitations (47.3%). Cardiac tamponade developed in 9.7% (n = 9) of the patients. Pericardial taps were performed in 64.5% of the cases. Our analysis showed that the most common cause of PE was cardiac disease (n = 33, 35.4%), followed by tuberculosis (TB) (n = 25, 26.8%), uremic pericarditis (n = 24, 25.8%), and hypothyroidism (n = 10, 10.7%). Regarding the severity of PE based on echocardiographic findings, nearly half of the patients (n = 46, 49.4%) had mild PE, whereas 26.8% (n = 25) had moderate PE, and 23.6% (n = 22) had severe PE. Two-thirds of the cases (66.6%) were managed with furosemide, 48 (51.6%) patients were treated with an anti-inflammatory, hemodialysis was performed in 24 (25.8%) patients and antituberculous medications were administered to 7 (7.5%) patients. Out of the 93 patients, 24 (25.8%) died during the hospital stay. It was determined that the mortality risk of patients with renal failure was 7.518 times higher than those without (p = 0.004), and the risk for those with TB was 5.554 times higher than those without (p = 0.011). Other variables were not influential on mortality (p > 0.050). Our study results demonstrate the epidemiological profile of PE in Somalia. The leading causes of PE were cardiac diseases, uremic pericarditis, TB, and hypothyroidism. PE is a significant cause of morbidity and mortality in Somalia, especially in individuals with renal failure and TB infection.

Pericardial Effusion

Background: Pericardial effusion is defined as the accumulation of fluid in the pericardial sac, this can lead to life-threatening cardiac complications if not promptly diagnosed and managed effectively. This radiographic case study aims to demonstrate the crucial role of imaging techniques in diagnosing pericardial effusion, providing valuable insights into its characteristics, and guiding appropriate clinical interventions.
 Methods: This is a case study of a 37yr old patient with suspected cardiac failure who underwent diagnostic imaging, including chest X-rays and echocardiography. The imaging findings were analyzed to assess the extent and severity of the disease and to help in the treatment decisions.
 Results: The radiographic evaluation revealed a moderate pericardial effusion with characteristic findings on chest X-rays and echocardiography. The size, location, and hemodynamic impact of the effusion were assessed, informing the clinical team's decision to proceed with pericardiocentesis for therapeutic relief.
 Conclusion: This case study underscores the pivotal role of radiographic imaging, particularly echocardiography and chest X-rays, in diagnosing and characterizing pericardial effusion. Timely and accurate diagnosis is essential for appropriate management and the prevention of life-threatening complications. Radiographic imaging serves as an indispensable tool in guiding clinical decisions and improving patient outcomes.

NEUTROPHILIC HOWELL-JOLLY BODY-LIKE INCLUSIONS IN CONCURRENT HIV AND SARS COVID-19 VIRUS INFECTIONS

Abstract Introduction/Objective Howell-Jolly bodies are nuclear remnants found in red blood cells in various conditions such as post-splenectomy, sepsis, sickle cell disease, alcoholism, autoimmune disorders (lupus), and post-bone marrow transplantation. Howell-jolly body-like inclusions have also been documented in neutrophils, rarely in monocytes, lymphocytes, and other myeloid cells. We report an interesting case of Howell-jolly body-like inclusions found in the neutrophils of a patient who is concurrently infected with HIV and the SARS-COVID-19 virus. Methods/Case Report A 59-year-old HIV-positive woman on darunavir, cobicistat, emtricitabine, and tenofovir alafenamide, is a current smoker and has a past medical history of COVID-19 pneumonia and persistent leukopenia. She presented with complaints of worsening cough, fever, and chills for 3 weeks. Her physical examination revealed diminished breath sounds at the bases of bilateral lungs. Her complete blood count (CBC) revealed white blood cells of 3.1 x 109/L, red blood cells of 2.55 x 1012/L, hemoglobin of 7.6 g/dL, and platelets of 164 x 109/L. Her last CD4 count was unknown and the current was 11. A SARS-CoV-2 PCR test was positive. Nucleic acid amplification tests for other respiratory viruses, Anaplasma and Babesia were negative. A computerized tomography scan of the chest showed multifocal pneumonia with a moderate pericardial effusion. Her beta-d-glucan level was within normal limits. The peripheral blood smear exhibited numerous neutrophils with basophilic, “Howell-Jolly body-like” inclusions within their cytoplasm. Dohle bodies were also present. Blood culture was positive for methicillin-sensitive Staphylococcus aureus. Her bone marrow biopsy showed normocellular marrow with maturing trilineage hematopoiesis and mild myeloid left shift. The patient was treated with vancomycin and piperacillin-tazobactam. Results (if a Case Study enter NA) NA Conclusion The presence of Howell-Jolly body-like inclusions in granulocytes is thought to be the result of stressed or dysplastic granulopoiesis secondary to immunosuppressive drugs, viral infections, chemotherapy, post- transplantation, or myelodysplastic syndrome. An association with HIV infection has been previously described. However, to the best of our knowledge, this is the first case of Howell-Jolly body-like inclusions in a patient with concurrent COVID-19 and HIV infections. These inclusions must be distinguished from other similar intracytoplasmic inclusions including Barr bodies, Anaplasma, and those seen in Chediak-Higashi syndrome.

Abstract 17085: An Unusual Case of Severe Hypertrophic Cardiomyopathy in a 23-Year-Old Systemic Lupus Erythematosus Patient on Hydroxychloroquine

A 23-year-old female with Systemic lupus erythematosus (SLE), lupus nephritis, antiphospholipid syndrome, venous thromboembolism, stroke, Libman-Sacks endocarditis, and hypertension presented with right upper and lower extremity weakness, right facial droop, and aphasia. Her home medications included hydroxychloroquine, mycophenolate, apixaban, and losartan. ECG showed normal sinus rhythm, left atrial enlargement, ST and T wave abnormalities in V5 and V6. Computed tomography angiography of the brain showed left middle cerebral artery occlusion. Transthoracic echocardiogram (TTE) showed left ventricular ejection fraction of 65%, severe left ventricular hypertrophy, moderate pericardial effusion, and moderately thickened mitral valve (MV) leaflets. Transesophageal echocardiogram showed large vegetations on atrial aspect of both MV leaflets concerning for Libman-Sacks endocarditis. We attempt to investigate the cause of this hypertrophic cardiomyopathy (HCM) in a young patient with SLE. Few reported cases of HCM in patients with SLE were medication induced. Tacrolimus has been observed to induced HCM in a Japanese patient with dermatomyositis. Hydroxychloroquine has been associated with myocardial thickening. Its use can lead to enlarged myocardiocytes with intracytoplasmic vacuoles consisting of concentric lamellar myelin figures in single membrane bound vesicles, curvilinear bodies, glycogen accumulation and fused mitochondria. Hydroxychloroquine use led to reversible inhibition of lysosomal enzyme activity. Cessation of medication use in both cases led to reduction in left ventricle thickness. These patients, like our own, has no family history of aortic valve stenosis, mitral valve prolapse, or HCM. However, this patient’s use of hydroxychloroquine to treat her SLE can be assumed to be a contributing factor to her HCM. This could suggest possible screening with ECG and TTE in patients taking hydroxychloroquine.

Abstract 11763: A Unique Presentation of Heart Failure With Severe Pulmonary Hypertension and Pericardial Effusion in a Young Patient With a Ruptured Sinus of Valsalva Aneurysm

Case: 26 y/o female immigrant from a developing nation presented with shortness of breath at rest. On physical exam, she desaturated to 75% with minimal movement, had an audible pansystolic murmur, and 2+ pitting edema. Initial presentation was indicative of decompensated Heart Failure (HF). 2D Echocardiogram (Echo) showed a right sinus of Valsalva aneurysm (SOV) with a left to right shunt to the pulmonary artery, as well as, severe pulmonary hypertension (PHTN) and moderate pericardial effusion. CT Scan of the chest showed a right Ruptured SOV (RSOV) with a dissection flap extending into the aorta. Transesophageal Echocardiogram confirmed the diagnosis; noted a right RSOV extending into the pulmonary artery causing severe pulmonary HTN leading to HF and pericardial effusion. The patient underwent surgical correction with full recovery and resolution of symptoms. Conclusions: SOV is a rare cardiac complication with variable etiology. Congenital causes are often found early in age and resolved surgically. Cases regarding the management of adults, especially in the critical care setting, are not well described. Here we report a 26-year-old female who rapidly developed HF with PHTN and pericardial effusion secondary to an RSOV. This case shows the importance of Echo in managing HF and determining its etiology. Using Echo we saw a dilated Inferior Vena Cava of 2.7 cm characteristic of HF. Next, we were able to visualize a dilated RSOV with a shunt to the right, subsequent turbulent flow through the Aortic valve, and severe tricuspid regurgitation. Lastly, we were able to see elevated pulmonary artery systolic pressure secondary to the shunt, and subsequent pericardial effusion (fig 1). The patient's symptoms were initially managed with IV diuretics and resolved with surgery. This is a rare case of right-sided RSOV extending into the pulmonary artery, its successful treatment, and the important role of Echo in treating HF and PHTN.

Abstract 12450: Mystifying Masquerade: Renal Cell Carcinoma Associated Arteriovenous Fistula Presenting as High-Output Heart Failure

Case Presentation: 59 year-old woman with CKD stage 3b and hypertension presented with 3 months of progressive dyspnea, abdominal distension, bilateral lower extremity edema, and a 60-pound weight gain. Physical exam noted diffuse anasarca, with stable hemodynamics on room air. EKG revealed low voltage leads and chest X-ray demonstrated an enlarged cardiac silhouette. CT abdomen was remarkable for significant ascites, body wall edema, and a suspicious large right renal mass. Diagnostic paracentesis indicated cardiac ascites. Echocardiogram showed preserved ejection fraction, moderate pericardial effusion and an enlarged right side of the heart. Right heart catheterization confirmed high-output heart failure (HOHF). A suspected renal mass-related arteriovenous fistula (AVF) was confirmed through inferior vena caval and renal venogram blood gas sampling, indicating arteriovenous shunting within the renal mass. Hepatic venogram excluded portal hypertension. MRI abdomen confirmed a large necrotic right renal mass consistent with renal cell carcinoma (RCC). Symptoms significantly improved after nephrectomy, with aggressive diuresis, and therapeutic paracenteses leading to an 80-pound weight loss. Postoperative echocardiography illustrated decrease in pericardial effusion and right ventricular size. Cardiac MRI and stress test were unremarkable prior to planned immunotherapy for stage III RCC. Discussion: AVF and HOHF associated with malignancy are unusual presentations. RCC is the most prevalent underlying malignancy linked with AVF and is hypothesized to be a result of hypervascularity caused by a VHL gene mutation. The most often utilized imaging modalities for detecting a tumor-related AVF are contrast enhanced CT or MRI. When imaging is inconclusive, a venogram with blood gas sample, as observed in our case, may be considered to establish an RCC-associated AVF.

Abstract 14647: EchoNext: An ECG-Based Deep Learning Model to Detect Structural Heart Disease

Introduction: Early detection of structural heart diseases (SHD) can help improve patient outcomes. Electrocardiogram (ECG) based deep learning (DL) models have the potential to identify patients (pts) with undiagnosed disease in need of further testing such as echocardiography. Most models have focused on detecting a single abnormality. A few studies have attempted detection on a comprehensive aggregate set of outcomes, but with limited scope and external validation. Hypothesis: An ECG DL model can identify pts at risk for SHDs, with stable external validation performance regardless of hospital type (academic/community), clinical setting (inpatient/outpatient/emergency department), or demographics (race/ethnicity). Methods: We identified 426,659 ECG-echo study pairs since 2008 from 5 NewYork-Presbyterian-affiliated (NYP) hospitals, including Columbia, to train the EchoNext DL model. ECGs were associated with SHD if acquired within one year prior to an echo reporting left ventricular (LV) ejection fraction ≤45%, LV wall thickness ≥1.3cm, moderate or severe valvular disease, moderate or large pericardial effusion, moderate or severe right ventricular dysfunction, or pulmonary artery systolic pressure ≥45 mmHg. EchoNext was tested on unseen data from four other NYP hospitals, including Cornell. Results: In the external dataset (n=21,421 pts), 33% were identified with SHD. EchoNext achieved an area under the receiver operating characteristic curve (AUROC) of 0.85, with robust results with respect to individual hospital (AUROC range: 0.82-0.87), clinical setting (0.78-0.84), and patient race/ethnicity (0.84-0.86; Figure). Conclusion: EchoNext demonstrated excellent performance in detecting SHD in the largest multi-institutional, multi-racial external validation of such a model to date. This model may allow AI-enabled reflex referral to echocardiography from ECG. Prospective trials are ongoing to validate.

Abstract 16555: Neutrophil to Lymphocyte Ratio: A Marker of Inflammation in Pericardial Disease

Introduction: Neutrophil-to-lymphocyte ratio (NLR) reflects the intricate relationship between the innate and adaptive immune systems during inflammatory states. With NLR known to be a sensitive indicator of inflammation, its role as a marker in acute pericarditis is yet to be investigated. Here we describe a rare case of acute pericarditis with an elevated NLR highlighting the potential impact this marker can have within the diagnostic evaluation of pericardial disease. Clinical Case: 46-year-old male with a past medical history of long QT syndrome, crohn's disease, ankylosing spondylitis, psoriatic arthritis, and histoplasmosis who presented with a four-day history of pleuritic chest pain, fever, and chills. The patient had a recent admission two months prior for pericardial effusion s/p emergent pericardial window. Cultures then showed acute and chronic inflammatory granulation tissue and necrosis with no evidence of malignancy and negative stains for fungal organisms. He was discharged home with ibuprofen without improvement. Upon arrival, the patient was hemodynamically stable with a workup notable for leukocytosis of 13.82x 10 9 /l, elevated CRP of 22.5 mg/dL and ESR of 65 mm/hr. NLR was 7.0. Echocardiography showed preserved ejection fraction with moderate circumferential pericardial effusion (figure A). The patient was started on colchicine in addition to ibuprofen. The cardiac MRI obtained showed evidence of moderate active pericarditis (figure B, C). A decision was ultimately made to start inpatient anakinra with a plan to discharge on triple therapy with colchicine, ibuprofen, and rilonacept. Discussion: NLR has the potential to be a novel inflammatory marker in pericardial disease associated with pericardial inflammation and edema. A normal range of NLR is between 1-2, with values higher than 3.0 and below 0.7 considered pathological. Our case highlights the importance of NLR as a diagnostic and prognostic marker of pericardial disease.

Abstract 17846: Successful Treatment of Recurrent Pericarditis With Rilonacept in the Setting Of ATRA/ATO Use in Acute Promyelocytic Leukemia

Case Presentation: A 40-year-old female was admitted for a 4-day history of recurrent left-sided pleuritic chest pain. Physical examination was pertinent for tachycardia and presence of a pericardial friction rub. Past medical history included recently diagnosed Acute Promyelocytic Leukemia undergoing active chemotherapy. Complete blood count showed leukopenia. Brain natriuretic peptide was slightly elevated at 241 pg/mL. Electrocardiogram demonstrated sinus tachycardia with diffuse ST-segment elevation and PR-segment depression (Figure 1. A). Echocardiogram showed normal biventricular function with a small posterior and lateral pericardial effusion and small pericardial effusion adjacent to the right ventricle (Figure 1. B). Cardiac magnetic resonance (CMR) imaging showed a moderate circumferential pericardial effusion and increased pericardial signal on T2 STIR imaging and late gadolinium enhancement (LGE) (Figure 1. C, D). Given the constellation of symptoms and findings, the patient was diagnosed with acute pericarditis secondary to differentiation syndrome (DS) suspected to be due to her underlying malignancy and anti-cancer treatments. She was started on aspirin and colchicine. Steroids and rilonacept were later added for incomplete treatment response. On follow-up, she was doing well. Repeat CMR demonstrated mild to moderate pericardial delayed enhancement with no edema and no pericardial effusion (Figure 1. E,F). Discussion: The presentation of DS can vary, and consensus diagnostic criteria are lacking. Cases of myopericarditis with concurrent pericardial effusions have been reported in the setting of patients undergoing chemotherapeutic treatment with differentiating agents. Management is complicated and requires multi-disciplinary care. Our case illustrates that rilonacept may be considered as an alternative to corticosteroids in the treatment of recurrent pericarditis in a patient with a hematologic malignancy.

Abstract 16644: Unusual Manifestation of Acute Pericarditis in the Setting of Primary Biliary Cirrhosis

Introduction: Primary biliary cirrhosis (PBC) is an immune-mediated liver disease leading to destruction of intrahepatic bile ducts and cirrhosis. However, its association with pericarditis has not been investigated. Here, we describe a case of a female with PBC who presented with severe pericardial disease. Clinical Case: A 57-year-old female with past medical history of primary biliary cirrhosis, thrombocytosis and type 2 diabetes who presented with sudden onset sharp chest pain, worse with movement or breathing. Workup was notable for elevated D-dimer, CT chest with no evidence of pulmonary embolism but did reveal a moderate pericardial effusion, further confirmed on echocardiogram. Nuclear stress test was unremarkable. CRP 13 mg/dL and ESR 82 mm/hr. Given concern for pericarditis, she was started on colchicine and ibuprofen. On further evaluation in clinic, cardiac MRI showed severe LGE and edema consistent with active pericarditis (figure 1) with mild constrictive physiology and worsening inflammatory markers (ESR 95 mm/hr, us-CRP 118mg/L). Therefore, decision was made to start triple therapy with the addition of prednisone. Repeat cardiac MRI 6 months later showed resolution of LGE and pericardial edema (figure 2). Given clinical improvement, patient was tapered off steroids, started anakinra and weaned off ibuprofen and colchicine. She remained on anakinra for two years after which she was transitioned to single therapy with colchicine with no episodes of recurrence. Discussion: PBC commonly exists with liver autoimmune disorders, but its association with pericardial disease has not been investigated. NSAIDs are often used as first-line therapy for pericarditis, but can be detrimental in advanced liver failure, often seen in patients with PBC. Steroid use is not only advantageous in pericardial disease but also in PBC. As a result, it is critical to identify the link between pericardial disease and PBC to determine appropriate therapeutic management.

Abstract 18975: First Reported Case of SLE Associated Recurrent Pericarditis Treated With Rilonacept

Description of case: A 42 year old female presented with a 1 month history of exertional dyspnea and intermittent pleuritic chest pain. She had a 12-year history of systemic lupus erythematosus (SLE) and non-specific interstitial pneumonitis being managed with mycophenolate mofetil. Labs showed an ESR of 76 mm/hr and CRP of 5.5 mg/dL. CT chest ruled out pulmonary embolism but showed a moderate pericardial effusion, also seen on an echocardiogram. A cardiac MRI (cMRI) showed moderate diffuse circumferential pericardial enhancement. She was diagnosed with lupus pericarditis and initially treated with ibuprofen, colchicine, prednisone, and hydroxychloroquine; however, continued to have persistent symptoms over the next few months. Repeat cMRI showed a transition to effusive constrictive physiology. She was offered pericardiectomy but following shared decision making and multi-disciplinary discussion, she was started on Rilonacept. She experienced significant and sustained relief in symptoms, improvement in inflammatory markers and reduction of pericardial enhancement on cMRI. Discussion To the best of our knowledge, this is the first case of Rilonacept used to successfully treat recurrent pericarditis from SLE. Recurrence in chronic idiopathic pericarditis is thought to be driven by the innate immune system and Interleukin-1 (IL-1), while in autoimmune diseases, it is mediated by the adaptive immune system and Type 1 Interferon, which is associated with a poorer prognosis. The RHAPSODY and AIRTRIP trials demonstrating efficacy of IL-1 blockers in recurrent pericarditis excluded patients with autoimmune diseases. Use of IL-1 blockers to treat Lupus pericarditis has only been reported in 2 cases using Anakinra. Our patient’s positive response to Rilonacept suggests the presence of additional target pathways in autoimmune diseases that may mediate pericarditis recurrence. Future prospective studies are needed to elucidate this further.

Abstract 17431: A Rare Cause of Constrictive Pericarditis in a Case of Adult T-cell Lymphoma

Introduction: Adult T-cell lymphoma (ATCL) is a rare T cell lymphoproliferative malignancy that typically presents with lymphadenopathy, hepatosplenomegaly, lytic lesions, hypercalcemia or skin lesions. Cardiac involvement is rare. Case presentation: A 66-year-old male with a history of chronic kidney disease and hypertension presented with dyspnea. Transthoracic echocardiography revealed a moderate pericardial effusion and a left ventricular ejection fraction of 45%. Further workup with MRI and transesophageal echocardiography found extensive circumferential pericardial thickening with enhancement and extensive mediastinal and hilar lymphadenopathy along with a mass along the course of the superior vena cava with extension of disease into the right atrium along the right atrial wall (Figure 1). Endobronchial biopsy of the mediastinal lymph nodes was positive for T-cell lymphoma. Chemotherapy was initiated; however, the patient decided to focus on comfort measures only. Discussion: Cardiac involvement in ATCL is rare and usually detected in postmortem autopsies. Incidence is unknown, and experience is limited to case reports. The largest case series to date found 16 patients who had antemortem diagnosis of symptomatic cardiac involvement of ATCL. The characteristic features included infiltration of the myocardium, pericardial effusion, valvular lesions, and masses in the atrium, similar to what was seen in our patient. To our knowledge, there have been no reported cases of ATCL causing constriction. Prognosis is poor, with median survival of 5 months after development of symptoms (n = 15, range 0-120 months). Conclusion: The incidence of cardiac ATCL is unknown, but it is an extremely rare occurrence. It can present with a wide variety of cardiac involvement, including constriction. The prognosis of cardiac ATCL remains poor.

Predicting Preoperative Rupture from Imaging Alone in Acute Type A Aortic Dissection

Objective. To establish risk factors for predicting preoperative ruptures in patients with acute type A aortic dissection (ATAAD) based on computed tomography angiography (CTA) imaging features alone. Methods. We retrospectively reviewed patients with ATAAD treated between January 2017 and December 2021 in Fujian Medical University Union Hospital, China. The primary outcome was preoperative rupture after admission. Multivariate logistic regression analysis was performed based on basic characteristics and CTA imaging variables selected by the application of the least absolute shrinkage and selection operator. Results. A total of 564 patients were enrolled. The rate of preoperative rupture was 14.2% (n = 80). Patients who experienced rupture were significantly older ( P = 0.002) and had a higher rate of DeBakey II ( P = 0.016), syncope ( P = 0.003), ventilator-assisted ventilation ( P = 0.008), preoperative shock ( P = 0.040), hypotensive state ( P = 0.009), hepatic insufficiency ( P = 0.002), acute kidney injury ( P = 0.045), and moderate or massive pericardial effusion ( P = 0.007). Multivariate analysis identified the following independent risk factors for preoperative rupture based on CTA imaging features: DeBakey II (odds ratio (OR) = 1.988, 95% confidence interval (CI) 1.211–3.676, P = 0.009), ascending aorta diameter (OR = 2.077, 95% CI 1.335–4.045, P < 0.001), ascending aorta false lumen diameter (OR = 2.988, 95% CI 2.055–4.291, P < 0.001), ascending aorta false lumen/true lumen diameter ratio >4 : 1 (OR = 3.129, 95% CI 2.031–6.225, P < 0.001), and number of branch arteries involved in dissection >6 (OR = 1.154, 95% CI 1.036–2.006, P = 0.036). Conclusions. CTA imaging features are one of the most convenient indicators for the early prediction of preoperative rupture in patients with ATAAD.