Pulsus Paradoxus Research Articles

Incidence of Malignancy Related Pericardial Effusion in a Tertiary Hospital

Back ground: Malignancy related pericardial effusion (PE) may represent a terminal event in patients with therapeutically unresponsive disease. Pericardial tamponade (PT) is a co morbid condition in many diagnosed malignant cases. Selection of patients with malignancies who are responsive to available treatment may achieve significant improvement in palliation. Early detection of pericardial tamponade and appropriate intervention (Pericardiocentesis) or Subxyphoid pericardiotomy may result long term survival benefit.Objective: Early detection and management of PE and tamponade in malignant cases.Methods: Color Doppler (C-D) echocardiography was done in 260 patients with underlying malignancies on chemo or radiotherapy from oncology department of Delta Medical college and hospital from May 2016 to December 2016. These cases were reviewed retrospectively for clinical features, diagnosis and therapy for their malignancy.Results: 81% have shortness of breath, sign of pulsus paradoxus and pericardial tamponade were found in 22% and 5% patients respectively. During echocardiography, pericardial effusion was found in 102 patients. 65% have mild pericardial effusion, whereas 27% have moderate and 8% have severe PE. Effusions with malignancy comprising of 40% adenocarcinomas of lung, 15% carcinoma (Ca) of pharynx, 10% Ca breast, 10% lymphoma, 10% is Carcinoma of unknown primary, 8% Ca esophagus and 7% others (Renal, Hepatic, ovary & cheek).University Heart Journal Vol. 12, No. 1, January 2016; 23-25

The value of dynamic preload variables during spontaneous ventilation.

To discuss the physiological significance and clinical value of dynamic preload variables in spontaneously breathing patients. Dynamic preload variables reflect the response of the cardiac output to a modification of preload and can therefore be used to assess fluid responsiveness. Continuous dynamic parameters that are calculated from the variations in the arterial and plethysmographic waveforms following a mechanical breath have been shown to predict fluid responsiveness much better than static preload parameters. These parameters are displayed on many patient monitors though their use is limited to mechanically ventilated patients. However, spontaneous breathing may also induce significant hemodynamic changes because of the repetitive negative swings in the pleural pressure. By better understanding the physiological basis of these changes, the same 'dynamic parameters' can be used to gain unique physiological insights during spontaneous breathing. These include the ability to identify and/or monitor respiratory rate, respiratory effort (e.g., patient-ventilator asynchrony), fluid responsiveness (to some degree), pulsus paradoxus (e.g. asthma, cardiac tamponade), and, importantly, upper airway obstruction. Although originally intended to be used only during mechanical ventilation, 'dynamic parameters' may offer valuable clinical information in spontaneously breathing patients.

Double whammy: the disappearing right atrium

A 66-year-old man with hepatitis C virus (HCV) infection complicated by liver cirrhosis presented with about 6 months of severe right shoulder pain as well as more recent progressive dyspnoea...

Diagnosis and Acute Management of Cardiac Tamponade

Cardiac tamponade is a medical and surgical emergency that requires quick recognition and treatment by the critical care provider. Tamponade results from accumulation of fluid in the pericardial space leading to equalization of pressures between the pericardial space, atria, and ventricles. This alteration in physiology causes hemodynamic changes that can range from tachycardia and hypotension to cardiovascular collapse. Diagnosis relies on a high index of suspicion and accurate interpretation and use of multiple diagnostic modalities. One of the most important tools, echocardiography, plays a vital role in the diagnosis, monitoring, and treatment of tamponade. Treatment depends on the hemodynamic stability of the patient and may include advanced cardiac life support, emergent pericardiocentesis, emergent sternotomy, or medical management. This review discusses the acute diagnosis and management of cardiac tamponade specifically related to surgical patients cared for by the critical care provider. This review contains 2 figures, 2 tables, 5 videos, and 55 references. Key words: atrial and ventricular collapse, cardiac tamponade, cardiogenic shock, critical care echocardiography, equalization of pressures, hemopericardium, pericardial effusion, pericardiocentesis, pulsus paradoxus, ventricular interdependence

Emergency Autotransfusion for Managing Iatrogenic Hemorrhagic Pericardial Effusion

Iatrogenic hemorrhagic pericardial effusion (IHPE) is one of the major complications encountered in daily percutaneous intracardiac interventions. A 79-year-old man was scheduled for percutaneous left atrial appendage closure (PLAAC) at our department. He had non-valvular atrial fibrillation, with a contraindication to oral anticoagulants because of a history of recurrent significant intestinal bleeding with angiodysplasia. During the deployment of the PLAAC device (Watchman device), patient became hemodynamically unstable with a typical decrease in the systolic arterial pressure of more than 10 mm Hg during inspiration (pulsus paradoxus) because pericardial tamponade occurred due to perforation of the left atrial appendage. We report our successful experience with management of IHPE by immediate pericardiocentesis, insertion of percutaneous catheter drainage (PCD), and retransfusing drained pericardial blood through a central venous line. IHPE is not uncommon complication in daily percutaneous intracardiac interventions. Pulsus paradoxus is the most important clinical sign of cardiac tamponade. Our approach by immediately retransfusing drained pericardial blood through a central venous line allowed rapid physiologically appropriate recovery. Future consensus of opinion of experts focusing on autotransfusion in such cases is needed. J Med Cases. 2017;8(4):114-116 doi: https://doi.org/10.14740/jmc2789w

Giant tubercular pericardial cyst leading to tamponade physiology.

A 56-year-old woman admitted to our department with chief complaints of fever, cough, dyspnoea since 3 months. No significant history. Physical examination revealed paradoxical pulse, raised JVP with prominent X, and absent Y descent. No other abnormal finding on physical examination. X-ray chest showed obliteration …

Pulse Oximetry: Beyond SpO2.

Newer pulse oximetry technology is available that uses multiple wavelengths of light and is thereby able to measure more than 2 forms of hemoglobin, including carboxyhemoglobin (SpCO), methemoglobin (SpMet), and total hemoglobin (SpHb). Several studies have shown relatively low bias, but poor precision, for SpCO compared with HbCO. Evaluations of SpMet have been conducted primarily in normal subjects. Clinical evaluations of SpHb suggest that it might not yet be accurate enough to make transfusion decisions. Respiratory waveform variability of the pulse oximeter plethysmogram might be useful to assess pulsus paradoxus in patients with airway obstruction; it might also be used to measure the breathing frequency. The change in pulse pressure over the respiratory cycle has been used to assess fluid responsiveness in mechanically ventilated patients, and similarly, the pulse oximetry plethysmogram waveform amplitude variability might be used to assess fluid responsiveness. However, there are limitations to this approach, and it remains to be determined how well it can be applied clinically using existing pulse oximetry technology. The pulse oximeter signal is probably useful for applications beyond SpO2 However, the current technology is not mature, and improvements are necessary. With technology improvements, the use of pulse oximetry to detect SpCO, SpMet, SpHb, pulsus paradoxus, breathing frequency, and fluid responsiveness is likely to improve in the future.

Abstract 12746: A Case of Biopsy-Proven Erdheim-Chester Disease Manifesting With Pan-Aortitis, Coronary Artery Encasement, a Large Pericardial Effusion, Orbital Pseudotumors, and a Right Heart Mass

A 72 year-old woman with a distant history of a cryptogenic right middle cerebral artery stroke presented with three days of fatigue, confusion, and recrudescence of old stroke symptoms. . Head and neck imaging demonstrated a small subarachnoid hemorrhage, orbital pseudotumors, cerebellar lesions, and circumferential thickening of the aortic arch and great vessels. Additional imaging of the chest, abdomen, pelvis, and legs revealed a large pericardial effusion, pan-aortitis, and sclerotic intramedullary lesions in both femurs. An electrocardiogram showed sinus rhythm, RBBB, and low voltage. Pulsus paradoxus was 10 mmHg. Laboratory analysis was notable for elevated serum inflammatory markers. Echocardiogram showed brief right ventricular diastolic inversion and a right atrioventricular groove mass. Diagnostic and therapeutic pericardiocentesis yielded 350cc of serosanguinous fluid, and evaluation for rheumatologic, infectious, and neoplastic etiologies was unremarkable. Cardiac magnetic resonance imaging (MRI) confirmed the presence of a right atrioventricular groove pseudotumor with avid late gadolinium enhancement and non-obstructive fibrotic encasement of the right and left anterior descending coronary arteries. The combination of pan-aortitis, orbital pseudotumors, pericardial effusion, coronary encasement, and right heart pseudotumor raised suspicion for Erdheim-Chester disease. Femoral bone biopsy revealed infiltration by CD68 (+), CD1a (-) histiocytes, confirming this diagnosis. Genetic testing identified a mutation in the gene for B-type RAF Kinase (BRAF) protein. Treatment with vemurafenib, a BRAF inhibitor, was initiated, and the patient’s disease has not progressed in the eighteen months since starting this treatment. Erdheim-Chester disease is a rare systemic illness caused by proliferation of non-Langerhans cell histiocytes. Cardiovascular manifestations—such as those seen in this case—complicate a majority of cases, and are the predominant cause of death. At least 50% of cases have mutations in the BRAF gene. While Erdheim-Chester disease has no known cure, vemurafenib represents a promising new therapy for BRAF mutation (+) cases.

Giant Thymoma and Cardiac Tamponade

SESSION TITLE: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: The thymus is a gland overlying the pericardium and great vessels in the anterior mediastinum that typically involutes after puberty. Thymomas are rare tumors of the thymus gland in which associated pericardial effusions are found in a minority while hemorrhagic pericardial effusion causing tamponade physiology is extremely rare (1). We present a case of a patient who had hemorrhagic pericardial effusion with cardiac tamponade due to a malignant Type B2 Thymoma. CASE PRESENTATION: A 51-year-old previously healthy male presented to the hospital with a four-week history of progressive dyspnea on exertion, orthopnea, and pleuritic chest pain, as well as, six months of 40-pound weight loss. On examination, he was found to be tachycardic with normal heart sounds, distended neck veins, and bilateral basal lung rales. Pulsus paradoxus was 24 mm Hg. Electrocardiogram showed sinus arrhythmia with tachycardia, diffuse low voltage QRS complexes and T-wave flattening in the inferior leads, without electrical alternans. His CBC showed leukocytosis with lymphocytic predominance. Other labs, including ESR, CRP, TSH, ANA, HIV, Rheumatoid Factor, syphilis and myasthenia gravis antibodies, were within normal limits. A Chest X-ray demonstrated an enlarged Cardiac silhouette and a large anterior mediastinal mass. Transthoracic echocardiogram showed a large pericardial effusion with tamponade physiology, as well as, a mass anterior to the right heart. An urgent pericardiocentesis was performed draining 640 ml of bloody fluid with the resolution of tamponade. Chest CT confirmed a large anterior mediastinal mass (16.3 x 19.5 x 20.6 cm) with central areas of necrosis and significant mass effect on the heart, trachea, and the bilateral main stem bronchi. Subsequently, the patient underwent mediastinoscopy with biopsy and flow cytometry demonstrating malignant Type B2 Thymoma. The patient was treated with neoadjuvant chemotherapy with cisplatin, doxorubicin, cyclophosphamide, and prednisone. He then underwent surgical debulking with plans for radiation therapy. DISCUSSION: The overall incidence of thymoma is 0.15 cases per 100,000 (2). Hemorrhagic pericardial effusion with cardiac tamponade represents a rare initial presentation of Malignant Thymoma. CONCLUSIONS: Thymic pathologies should be included as a rare etiology in the differential diagnosis of hemorrhagic pericardial effusion and cardiac tamponade. To the best of our knowledge, this case represents the largest malignant thymoma that has been diagnosed with a presentation of hemorrhagic pericardial effusion and cardiac tamponade Reference #1: Takanami I, Takeuchi K, Naruke M. Noninvasive large thymoma with a natural history of twenty-one years. J Thorac Cardiovasc Surg. 1999;118:1134-1135. doi: 10.1016/S0022-5223(99)70120-0. Reference #2: Engels EA, Pfeiffer RM: Malignant thymoma in the United States: demographic patterns in incidence and associations with subsequent malignancies. Int J Cancer 105(4):546-51, 2003 DISCLOSURE: The following authors have nothing to disclose: Irfan Ahsan, Wisam Alfay, Jenna Jarriel, Gregary Marhefka No Product/Research Disclosure Information

Can We Assess Pulsus Paradoxus through Polysomnography in a Patient with Chronic Obstructive Pulmonary Disease and Sleep-Disordered Breathing?

Pulsus paradoxus (PP) is a decrease in systolic blood pressure greater than 10 mm Hg during inspiration that occurs in various medical conditions. Using polysomnography pulse oximetry signal, photoplethysmography variations of the amplitude of the pulse pressure within the respiratory cycle were observed. There is a proportional relationship between the changes of inspiratory waveform values and the generated PP. A 59-year-old male underwent polysomnography that showed sleep hypoxemia, obstructive sleep-disordered breathing (apnea hypopnea index [AHI] = 5.1and respiratory disturbance index [RDI] = 87.9), with variations of pulse pressure induced primarily by inspiration. The highest variations in the pulse wave were observed in NREM sleep during obstructive respiratory events and in biocalibration during nasal breathing. The lowest variations occurred after the correction of inspiratory obstructive events and during biocalibration when asked to hold his breath.

Improved hyponatremia after pericardial drainage in patients suffering from cardiac tamponade.

BackgroundSome case reports showed unexplained hyponatremia in patients with cardiac tamponade. Reversible hyponatremia was observed in these patients who received pericardial drainage. The occurrence rate of hyponatremia in patients of cardiac tamponade is not clearly known. The objective of this study was to identify the relationship between hyponatremia, cardiac tamponade and their underlying diseases.MethodsWe reviewed the clinical data of patients with cardiac tamponade and receiving pericardial drainage between January 2000 and January 2012 in our hospital. Cardiac tamponade was diagnosed by clinical presentation: hypotension, pulsus paradoxus, and increased jugular vein pressure. We used paired T test to compare the sodium change before and after pericardial drainage. Pearson’s chi-square test was used to analyze the relationship of hyponatremia with malignancy and cardiac chamber compression proved by echocardiography.ResultsFor the 48 patients, the mean pre-drainage sodium level was 129.1 ± 7.1 mEq/L and the mean post-drainage sodium level was 130.4 ± 5.6 mEq/L (p = 0.06). Among the 48 patients, 31 (65 %) had hyponatremia. For the 31 hyponatremia patients, the mean pre-drainage sodium level was 124.8 ± 4.9 mEq/L and the mean post drainage sodium level was 127.5 ± 4.5 mEq/L (p = 0.003). Hyponatremia was significantly associated with malignancy (p = 0.038). There was no significant change of pre-drainage and post-drainage sodium level in patients without malignancy. The post-drainage sodium level in the malignant patients significantly increased from 125.5 ± 8.0 to 129.1 ± 5.5 mEq/L (p = 0.017). The presence of hyponatremia was strongly associated with the cardiac tamponade sign (p < 0.001). After pericardial drainage, the sodium level significantly increased in patients with chamber compression than in patients without compression.ConclusionHyponatremia is associated with cardiac tamponade especially for malignant pericardial effusion and for patients with cardiac chambers compression signs. Hyponatremia can be improved after pericardial effusion drainage.

Assessment of the effects of inspiratory load on right ventricular function.

The right ventricle (RV) plays a pivotal role during respiratory failure because of its high sensitivity to small loading changes during inspiration. Both RVs, preload and afterload, are altered during inspiration, either in spontaneous breathing or during mechanical ventilation. Some clinical situations especially affect RV load during inspiration, for example acute asthma and acute respiratory distress syndrome. The aim of this review is to explain and to summarize the different mechanisms leading to RV failure in these situations. Research has recently reemphasized the importance to well known physiology of the venous return which is a contributor of RV preload. Authors recently focused on the mean systemic filling pressure which is one of the determinants of venous return. Venous return may change in opposite direction according to the type of ventilation (spontaneous or assisted). Recent works have also demonstrated the crucial impact of lung inflation and driving pressure on RV afterload, and have confirmed the deleterious effect of severe RV failure, described as acute cor pulmonale. In most situations of RV overload induced by inspiration, significant pulse pressure variations are observed, either called 'pulsus paradoxus' in spontaneously breathing patients or 'reverse pulsus paradoxus' in mechanically ventilated patients. RV is very sensitive to abnormal inspiration, which is always responsible for an increase in its afterload. Pulse pressure variations, central venous pressure and especially echocardiography may monitor RV function in abnormal clinical situations. The pulmonary artery catheter was also proposed although now less used.

The efficacy of nebulized magnesium sulfate alone and in combination with salbutamol in acute asthma.

ObjectiveEvaluation of the efficacy of nebulized magnesium sulfate (MgSO4) alone and in combination with salbutamol in acute asthma.MethodsA double-blind randomized controlled study was conducted in Chest and Emergency Departments. Thirty patients of acute attack of bronchial asthma were randomized into three groups: MgSO4 nebulization (group A), salbutamol nebulization (group B), and their combination (group C). All patients were monitored before and after nebulization (each 20 minutes) for peak expiratory flow rate (PEFR), respiratory rate (RR), heart rate (HR), blood pressure, pulsus paradoxus, oxygen saturation, clinical examination, and Fischl index.ResultsA highly significant improvement in PEFR, PEFR percentage, and Fischl index and significant decrease in RR and HR was observed in all groups. A similar improvement in PEFR was observed in group A and group B (P=0.389). The difference in peak expiratory flow (PEF) improvement was insignificant between group B and group C (P=0.101), while there was a significant difference between group A and group C (P=0.014) in favor of group C.ConclusionNebulized MgSO4 alone or combined with salbutamol has a clinically significant bronchodilator effect in acute asthma and leads to clinical improvement, increase in PEFR, reduction in HR, and reduction in RR. The response to nebulized MgSO4 alone (PEFR improvement 54±35.6 L/min, P=0.001) is comparable (P=0.389) to that of nebulized salbutamol (PEFR improvement 67.0±41.9 L/min, P=0.001) and is significantly less than (P=0.014) that of nebulized combination (PEFR improvement 92.0±26.9 L/min, P=0.000).

An Emergent Echo-Guided Apical Pericardiocentesis for Cardiac Tamponade in a Patient with only the Left Lung

On physical examination, his blood pressure was 90/70 mm Hg, heart rate 130 beats per minute. There was elevated jugular venous pressure, peripheral oedema and pulsus paradoxus. The electrocardiogram showed sinus tachycardia with low voltage and a thoracic Computed Tomography (CT) revealed severe pericardial effusion (Figure 1). Because of this, the patient was immediately admitted to our Intensive Care Unit (ICU). A bedside echocardiogram confirmed the large pericardial effusion and a right atrium diastolic collapse. The poor quality sub-xiphoid pericardial window did not allow the visualization of a pericardial sack, which was detected by parasternal and apical views (Figure 1).

Decipherment and annotation of a manuscript of Tibetan medicine in Dunhuang scroll (Part I)-on pulse-taking

A manuscript of Tibetan medicine, P. t.1054 is recorded in the Volume 10 of Dunhuang Tibetan Manuscripts Preserved in France, which is written in 4 pattra-leaf-like rectangular papers connected together. The content in the front side is the pulse-taking of Tibetan medicine, and the back, on prescription. For the pulse-taking, it deals with the manifestations, time and position for pulse-taking, paradoxical and death pulse. There is no information about the title, author, editor, translator, copyist or collector.

Female With Severe Shock

A 51-year-old woman presented to the emergency department (ED) with severe shock, unresponsiveness, and motor restlessness. She had been found unconscious in an open field with horses. Primary survey revealed a self-maintained airway and spontaneous breathing without external blood loss. Glasgow Coma Scale score was 7. Complete physical examination revealed parasternal bruising resembling a horseshoe print (Figure 1). Initial systolic blood pressure was between 70 and 90 mm Hg, with a pulse rate of 130 beats/min, with no improvement despite volume replacement with 0.9% normal saline solution. After intubation, a markedly elevated jugular venous pressure was observed and sinus tachycardia persisted. A pulsus paradoxus was not observed. Chest radiograph showed an enlarged cardiac silhouette (Figure 2). Abdominal ultrasonography result was normal. Bedside cardiac ultrasonography was not available in the ED.Figure 2Chest radiograph showing enlarged cardiac silhouette.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Cardiac tamponade caused by a blunt thoracic trauma. Initial diagnosis of traumatic cardiac tamponade is difficult, especially in blunt chest injury. Clinical suspicion increases when sinus tachycardia, elevated jugular venous pressure, or pulsus paradoxus is present and irresponsive to volume replacement.1Spodick D.H. Acute cardiac tamponade.N Engl J Med. 2003; 349: 684-690Crossref PubMed Scopus (530) Google Scholar Blood in the pericardial sac causes pressure on the cardiac ventricles and reduces diastolic compliance, and then causes a decrease in systemic and venous return, and eventually death from cardiogenic shock, ie, cardiac tamponade.1Spodick D.H. Acute cardiac tamponade.N Engl J Med. 2003; 349: 684-690Crossref PubMed Scopus (530) Google Scholar, 2Von Wachenfelt H, Nilsson C, Ventorp M. Measurement of kick loads from horses on stable fittings and building elements. 2013. Available at: http://pub.epsilon.slu.se/10949/7/wachenfelt_etal_131220.pdf. Accessed April 2, 2015.Google Scholar, 3Fitzgerald M. Spencer J. Johnson F. et al.Definitive management of acute cardiac tamponade secondary to blunt trauma.Emerg Med Australas. 2005; 17: 494-499Crossref PubMed Scopus (47) Google Scholar Our patient immediately underwent needle pericardiocentesis at the ED (Figure 3), where 150 mL of blood was drained, resulting in hemodynamic stability. After the pericardiocentesis, right-sided cardiac failure developed, which was successfully treated with diuretics. The patient fully recovered and was discharged home after 9 days.

Low-pressure cardiac tamponade: A case report

A 57-year-old woman presented with a large idiopathic pericardial effusion with subsequent cardiac tamponade, in whom the intrapericardial pressure measured by pericardiocentesis was not elevated. The patient did not present with the classical clinical features of cardiac tamponade, requiring echocardiographic follow-up to make accurate diagnosis and treatment. This entity called low-pressure cardiac tamponade has been diagnosed anecdotally being an insidious condition that requires a high degree of suspicion.<Learning objective: Low-pressure cardiac tamponade is a clinical condition whose clinical diagnosis is highly difficult due to the dramatic loss of sensitivity of the classical clinical findings (dyspnea, tachycardia, hypotension, central venous pressure, and paradoxical pulse), making the diagnosis challenging. It requires a high index of suspicion at the echocardiographic study moment, and as in the classic cardiac tamponade many cases eventually require pericardiocentesis for confirmation and treatment.>

Pulse Oximeter Plethysmograph Estimate of Pulsus Paradoxus as a Measure of Acute Asthma Exacerbation Severity and Response to Treatment.

Pulsus paradoxus is one of the few objective bedside measures of acute asthma exacerbation severity but is difficult to measure in tachypneic and tachycardic patients and in noisy clinical environments. Our primary objective was to examine whether pulse oximeter plethysmograph estimate of pulsus paradoxus (PEP) is associated with physiologic and symptom measures of acute exacerbation severity (airway resistance by impulse oscillometry [%IOS] and the Acute Asthma Intensity Research Score [AAIRS]). Secondary objectives were to validate the previous association of PEP with percent predicted forced expiratory volume in 1 second (%FEV1 ) and to examine associations of change of PEP with change of these outcomes after 2 hours of treatment. This was a secondary analysis of data from a prospective observational study of patients aged 5-17 years with acute asthma exacerbations. The predictor variable, PEP, was measured using a dedicated pulse oximeter and waveform analysis program. Outcome measures included the AAIRS, %IOS, and %FEV1 at baseline and after 2 hours of treatment. We examined associations of PEP with %IOS and the AAIRS at baseline using multiple linear regression models adjusted for age, sex, and race. As secondary analyses we similarly examined the association of PEP with %FEV1 at baseline and change of PEP with change of %IOS, the AAIRS, and %FEV1 after 2 hours of treatment using multiple linear regression models adjusted for the baseline value of the outcome measure and the AAIRS. Among 684 participants (61% males; 61% African American) there were associations of baseline PEP with %IOS, the AAIRS, and %FEV1 (p < 0.001). Change of PEP after 2 hours of treatment was associated with change of %FEV1 (p < 0.001) and change of the AAIRS (p = 0.01) but not with change of %IOS (p = 0.60). PEP demonstrates criterion validity in predicting baseline %IOS, the AAIRS, and %FEV1 , and responsiveness to change of the AAIRS and %FEV1 . Data contained in the oximeter plethysmograph waveform might be utilized as a continuous, objective measure of acute asthma exacerbation severity and real-time response to treatment.

Purulent pericarditis caused by Klebsiella pneumoniae in a Nigerian Child

In the Western world, cases of purulent pericarditis have become almost nonexistent with progress and advent of new immunizations against many causative organisms. We report Klebsiella pneumoniae pericarditis, a rare cause of this uncommon disease, hitherto unreported in Nigeria. K. pneumoniae, which is a rod-shaped, Gram-negative, facultative anaerobe, produces extended-spectrum beta-lactamases; hence, it is usually resistant to a lot of antibiotics and is associated with a significant case fatality rate. Our 13-year-old male patient had septic arthritis of the right hip joint came with a 3 weeks complaint of difficulty with breathing. He had respiratory distress, tachypnea, and tachycardia. Although blood pressure was normal, he had pulsus paradoxus, elevated jugular venous pressure, diffuse apex beat, and heart sounds were distant. Chest radiograph revealed an increased cardiothoracic ratio (0.86) with “water bottle” appearance. Transthoracic echocardiography confirmed pericardial effusion with cardiac tamponade. Echo-guided pericardiocentesis was done, and 340 ml of foul-smelling and creamy pus with greenish tinge was aspirated and this grew K. pneumoniae sensitive to ciprofloxacin and gentamycin but resistant to other conventional antibiotics. Recovery was complete after a week of pericardial tube drainage and 3 weeks of treatment. To the best of our knowledge, this is the first case of Klebsiella - induced pyopericardium and with successful management in a Nigerian child. Pyopericardium may follow rare causes such as K. pneumoniae infection with its unique antibiogram.

Pericardial Effusion due to Primary Malignant Pericardial Mesothelioma: A Common Finding but an Uncommon Cause.

This case report describes a 37-year-old female who was admitted to our Emergency Department because of shortness of breath. On physical examination, she had dyspnea and tachycardia and blood pressure was 80/50 mmHg with a pulsus paradoxus of 22 mmHg. Neck veins were distended, heart sounds were distant, and dullness was found on both lung bases. Her chest X-ray revealed bilateral pleural effusion and cardiomegaly. On both computed tomography and echocardiography the heart was of normal size and a large pericardial effusion was noted. The echocardiogram showed signs of impending tamponade, so the patient underwent an emergent pericardiocentesis. No infectious etiology was found and she was assumed to have viral pericarditis and was treated accordingly. However, when the pericardial effusion recurred and empirical therapy for tuberculosis failed, a pericardial window was performed. A typical staining pattern for mesothelioma was found on her pericardial biopsy specimen. Since no other mesodermal tissue was affected, a diagnosis of primary malignant pericardial mesothelioma was made. Chemotherapy was not effective and she passed away a year after the diagnosis was made. This case highlights the difficulties in diagnosing this uncommon disease in patients that present with the common finding of pericardial effusion.