Pericardial Infiltration Research Articles

Pericardial infiltration and constriction due to cardiac actinomycosis—case report

Abstract Background Constrictive pericarditis associated with actinomycosis infection is a rare and challenging diagnosis due to its insidious manifestation. We describe the successful treatment of pericardial infiltration and constriction due to actinomycosis. Case summary A 50-year-old Aboriginal man presented with insidious onset of fatigue, dyspnoea, pleuritic chest pain, fever, drenching sweats, severe exercise intolerance to 50 m, and recurrent itchy skin lesions over 8 months. Prior investigations, including serial fluorodeoxyglucose (FDG)-Positron emission tomography scans, found a progressively enlarging, metabolically active anterior mediastinal mass with two biopsies on separate occasions showing no malignancy, granulomas, tuberculosis, or other pathology. Screening for infective, autoimmune, and connective tissue disease was negative. A transthoracic echocardiogram (TTE) showed fibrinous pericarditis with extensive myocardial tethering and constrictive physiology confirmed on heart catheterization. A pericardial biopsy showed inflammatory tissue only. Biopsy of a skin lesion on the buttock showed abscess formation with Splendore Hoeppli phenomenon with Gram-positive and Grocott-positive filamentous bacteria suggestive of actinomyces, confirmed by 16S rRNA gene sequencing. He was diagnosed with cardiac actinomycosis, likely due to mediastinal infiltration from a lung infection, with haematogenous spread and treated with Penicillin G with adjunctive high-dose steroid therapy with resolution of symptoms and marked improvement in TTE features of constriction after 6 weeks. Discussion Actinomycosis is an extremely rare cause of pericardial infiltration and constriction yet highly sensitive to penicillin, highlighting the importance of accurate diagnosis. Corticosteroids are a useful adjunct to prevent chronic constrictive pericarditis and to avoid the high morbidity and mortality associated with pericardiectomy.

Pericardial Windows: The Limited Diagnostic Value of Non-Targeted Pericardial Biopsy.

Pericardial window, in addition to promoting pericardial drainage, can also provide samples of the pericardium for anatomopathological examination. However, such biopsies' contribution to clarifying the etiology of pericardial effusion has been debated. To analyze the diagnostic value of non-targeted pericardial biopsy obtained from pericardial window procedures. Data from 80 patients who had undergone parietal pericardial biopsies from 2011 to 2020 were retrospectively reviewed. Statistical significance was considered if p < 0.05. Fifty patients were male (62.5%,) and 30 were female (37.5%). The median age was 52 years (interquartile range: 29 to 59) and 49 years (interquartile range: 38 to 65), respectively (p = 0.724). The suspected etiology of pericardial effusion was neoplastic in 31.3%, unclear in 25%, tuberculosis in 15%, autoimmune in 12.5%, edemagenic syndrome in 7.5%, and other miscellaneous conditions in 8.8%. The most frequent approach for pericardial drainage and biopsy was subxiphoid (74%), followed by video-assisted thoracoscopy (22%). Overall, in 78.8% of the biopsies, the histopathologic findings were compatible with nonspecific inflammation, and only 13.7% of all biopsies yielded a conclusive histopathological diagnostic. Those suffering from cancer and pericardial effusion had a higher proportion of conclusive histopathologic findings (32% had pericardial neoplastic infiltration). The hospital mortality rate was 27.5%, and 54.5% of the patients who died in the hospital had cancer. No deaths were attributed to cardiac tamponade or the drainage procedure. Our results showed that pericardial window is a safe procedure, but it had little value to clarify the pericardial effusion etiology and no impact on the planned therapy for the primary diagnosis besides the cardiac decompression.

P423 RELAPSE OF ACUTE MYELOID LEUKEMIA WITH CARDIAC INFILTRATION: A CASE REPORT

Abstract We describe the case of a 42–year–old man who presented to the emergency department suffering from asthenia, dyspnea and tachycardia. The patient had been diagnosed, two years earlier, with acute myeloid leukemia (AML), treated with two lines of chemotherapy and allogeneic bone marrow transplantation from a family donor. Atrial fibrillation with rapid ventricular response was documented at the ECG. The echocardiogram showed moderate left ventricular dysfunction in the presence of dishomogeneous thickening of left and right ventricular wall and a severe circumferential pericardial effusion causing cardiac tamponade, with the need of urgent pericardiocentesis. AML relapse was documented at the laboratory tests. The suspected cardiac involvement was investigated with cardiac MRI which documented thickening and diffuse late gadolinium enhancement at the level of the left and right ventricular wall, the interatrial septum and the atria walls. The pericardium and the epicardial fat were also thickened and endowed with contrast enhancement. A lymphocyte assay was performed on pericardial fluid and showed the presence of a blast population (approximately 27% of white blood cells) with variable expression of myeloid antigens. The clinical, radiological and finally immunophenotypic picture therefore concluded with relapse of acute myeloid leukemia with myocardial and pericardial infiltration. Acute myeloid leukemia usually presents with symptoms related to bone marrow failure. Clinically significant cardiac involvement is rare but should be considered when cardiorespiratory symptoms occur. Cardiac manifestations include coronary artery disease, heart failure, conduction disturbances, myocarditis, pericarditis, and pericardial effusion. Understanding the underlying pathophysiology and recognizing potential cardiac manifestations could help in the early diagnosis, evaluation, and treatment of these patients. Echocardiography or cardiac MRI could reveal morphological, structural and signal abnormalities of the cardiac structures and therefore should raise the suspicion of a possible myocardial infiltration by leukemia cells, both in patients with a positive history of leukemia and in those in whom cardiac involvement could represent the first manifestation of a hematological pathology.

P132 A CASE REPORT OF A STEMI MIMICKER IN A PATIENT WITH TUMORAL MYOCARDIAL INFILTRATION AND LITERATURE REVIEW

Abstract Introduction We report a case of ‘STEMI–like’ presentation, with marked STE on ECG in a patient with lung cancer and cardiac catheterization showing no significant coronary obstruction. A 76y woman presented in the emergency room with dyspnea and chest pain.She had a history of hypertension, obesity, previous cerebellar ischemia and pulmonary neoplasia with involvement of left upper lobe and stenosis of main left bronchus and mediastinal infiltration, on palliative treatment.First ECG showed atrial fibrillation (AF) 150 bpm and marked convex STE in I and aVL leads with reciprocal changes, so urgent coronary angiography (CA) was performed. Initial therapy was BB, ASA and UFH. CA surprisingly showed no significant coronary obstruction. Transthoracic echo (TTE) showed a large mass involving pericardium and left atrium, with infiltration of left myocardial lateral wall with a fingernail shape. HS troponin reached 10xN. The STE persisted on subsequent ECGs. In conclusion the ECG changes are due to neoplastic infiltration of left ventricle lateral wall, while AF is due to atrial infiltration. Discharged on day3, the patient was maintained on palliative care plus BB but no antithrombotic therapy due to very high risk of pulmonary bleeding and hemorrhagic infarction of ventricular wall. In our case no Thoracic CT Scan was performed, so we cannot differentiate between cardiac muscular involvement by pericardial metastasis and infiltration by the primary tumor, which is more likely because of the anatomic relationship between left upper lobe and the heart. Discussion Cardiac metastases varies in incidence (2.3 –18.3%), decrease with age, and most frequently origin from respiratory system. They can involve any heart chambers, clinical patterns depend on degree and site of myocardial infiltration.When ventricular wall is infiltrated pseudo–ischemic ECG changes may be induced;persistency of STE suggests tumour compression and/or myocardial infiltration. Patients with known malignancy with chest pain and STE should be screened for cardiac metastases and treated with a single (and not double) antiplatelet agent until coronary stenosis are confirmed. If systemic thrombolysis is considered, a bedside TTE should be performed before therapy.

Pericardial malignant infiltration as the cause of sudden death of a patient with metastatic urothelial carcinoma treated with atezolizumab

BackgroundMuscle-infiltrating urothelial carcinoma of the bladder is the most common genitourinary cancer. Immunotherapeutic agents targeting protein-1 programmed death or protein-1 programmed death ligand are currently considered the standard treatment in patients with either inoperable locally advanced or metastatic urothelial carcinoma (MUC) after platinum-based chemotherapy failure.Case presentationHere we report the case of a Caucasian male patient with metastatic urothelial carcinoma treated with second-line atezolizumab within a trial who achieved complete response by computed tomography (CT), but suddenly died due to cardiac tamponade resulting from malignant pericardial infiltration. Histopathology confirmed this as the only site of disease progression.ConclusionsCardiovascular toxicity of atezolizumab was considered within differential diagnoses, however histopathological examination revealed progression of malignancy in the pericardium as the cause of the sudden death. This is the first published case report of a patient treated with second-line atezolizumab in whom the rare disease progression of pericardial infiltration was confirmed. Despite its rarity, the clinicians should always consider the possibility of pericardial metastases.

Role of MRI in evaluation and characterization of neoplastic and nonneoplastic cardiac masses

BackgroundThe overall frequency of cardiac tumors is quite low, with an estimated cumulative prevalence of 0.002–0.3% at autopsy, however, they represent an important group of cardiovascular abnormalities as the early and accurate diagnosis maybe curative and sometimes avoids unnecessary surgery.Aim and objectivesThe aim of this study was to evaluate the efficacy of MRI, in diagnosis, evaluation, and characterization of cardiac neoplasms, as identification and differentiation between the cardiac masses are of extreme importance to develop exquisite better therapeutic planning and positive prognostic results.Patients and methodsThis study is a prospective one that was conducted on 27 patients who were diagnosed to have cardiac masses by echocardiography or other imaging modalities. Contrast-enhanced MRI was done on closed Siemens MR Systems operating at 1.5 T in National Heart Institute in Giza. The study was performed after approval of the Ethical Committee of Scientific Research. Evaluation of cardiac masses was analyzed, regarding the involved chambers, pericardial violation, morphological characters, as well as their pattern of enhancement at contrast-enhanced cardiac MRI studies, aiming at characterization of different cardiac masses on MRI diagnostic bases.ResultsIn our study, we diagnosed 85.2% (23/27) of the cases as benign-looking lesions (including both true and pseudotumors), while 14.8% (4/27) as malignant-looking lesions. A statistical significant difference was noted, regarding the differentiation between the benign and the malignant lesions regarding the size, marginal outline, pattern of growth, and pericardial affection, either infiltration or effusion. As regards the pericardial affection, none of the benign lesions showed pericardial infiltration compared with 50% (2/4) of the malignant lesions that showed pericardial infiltration with a statistically significant P value of 0.017.ConclusionCardiac magnetic resonance imaging (CMR) has a great role in evaluation of the cardiac masses by its powerful assessment of the anatomical and soft-tissue characterization of the masses, as well as their functional impact, and so it allows the differentiation between neoplastic and nonneoplastic masses, as well as between malignant and benign masses.

60 Primary mediastinal large B-cell lymphoma: how to manage it during pregnancy

Abstract A 33 years old patient came to our attention, pregnant in her 26th week. She had dyspnoea, cough and weight loss (up to 45 kg of weight) in the previous two weeks. During urgent gynecological check-up she was found in poor general conditions, tachypnoic (respiratory rate &amp;gt;30 acts/minutes) with pale skin and bilateral jugular turgor. There was nothing relevant in her past medical history except for a thrombocytopenia appeared 2 months before. She consulted a haematologist who recommended to look for JAK2 mutation that was excluded. Echocardiography revealed a voluminous hypoechoic mass extrinsically imprinting the roof and the anterior wall of the right atrium that also involved inferior vena cava as a sleeve; a flow acceleration with an average gradient of 6 mmHg was documented at the level of right lower pulmonary vein and a possible infiltration of atrial wall was seen. Left ventricle was normal in size and kinesis; right ventricle also showed preserved contractility of the free wall with reduction in the distal outflow portion due to diffuse soft thickening that surrounded this portion and that extended cranially towards the trunk of pulmonary artery and ascending aorta. There also was a layer of circumferential pericardial effusion, apparently organized, with irregular profile of visceral pericardial sheet adjacent to diaphragmatic wall of right ventricle. On chest contrast computed tomography (CT) a voluminous mediastinal solid mass (13 × 16 × 18 cm) was confirmed with inhomogeneous enhancement for central necrotic components determining complete atelectasis of middle and upper right lung lobes and compression of superior vena cava, of some branches of pulmonary artery and ipsilateral pulmonary veins too; supra-aortic trunks and aorta were surrounded by the mass but open; the mass enveloped the right posterolateral area of the heart, displacing it to the left and compressing right atrium with apparent pericardial infiltration. Moreover there were approximately 16 mm of pericardial effusion and multiple mediastinal adenopathies. A chest and abdomen magnetic resonance confirmed the presence of the known voluminous heteroplastic formation occupying almost all right hemithorax, indissociable from the pericardium, with compression of right heart chambers and cavae veins. A thoracic biopsy of mediastinal mass was urgently performed under ultrasound guidance and followed by systemic steroid therapy. Histological examination showed off the diagnosis of primary large B cell lymphoma of the mediastinum (PMBCL, according to WHO classification 2016). A steroid therapy and chemotherapy cycles were started (Cyclophosphamide-Hydroxydaunorubicin-Oncovin-Prednisone—CHOP scheme). On the second day after chemotherapy, we saw a sudden worsening of clinical conditions: the patient had severe respiratory distress and signs of low cardiac output such as hypotension, elevated heart rate, increased blood lactates, low venous oxygen saturation (SVO2 45%), and elevation N-terminal prohormone of brain natriuretic peptide (NT-proBNP); she was therefore admitted to intensive care unit (ICU) where a gradual optimization of haemodynamic parameters. Then she underwent a second cycle of chemotherapy: dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) and was then successfully discharged. In such cases a careful evaluation and balancing of both haematological and gynecological–obstetric aspects is needed and it requires a multidisciplinary team approach in order to identify the best diagnostic and therapeutic pathway and, most of all, the best timing for delivery depending on gestational age.

Erdheim-Chester disease: a rapidly evolving disease model.

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis with a putative neoplastic and inflammatory nature. The disease is driven by mutations in proto-oncogenes such as BRAF and MEK, while immune-mediated mechanisms contribute to disease development and progression. The clinical presentation of ECD is highly heterogeneous, ranging from smouldering unifocal forms to multiorgan life-threatening disease. Almost any organ can be involved, but the most common lesions include long-bone involvement, retroperitoneal fibrosis, interstitial lung disease, pericardial and myocardial infiltration, CNS, retro-orbital, and large-vessel involvement. These manifestations may mimic those of neoplastic and systemic immune-mediated diseases. Overlap with these conditions represents an emerging challenge for the clinician. A variety of treatments are efficacious for ECD, targeting both the MAPK-pathway and the immune-mediated pathomechanisms. The traditional approach is based on immunomodulatory agents (interferon-α), but recent alternatives-including anti-cytokine therapies (IL1- and TNFα-blockers) and immunosuppressants (mTOR-inhibitors)-showed promising results. However, since the detection of MAPK pathway activation in most patients and the dramatic efficacy of BRAF and MEK inhibitors, these targeted treatments represent the first-line approach in patients with severe disease forms. High rates of radiologic responses do not often mean clinical remission, especially for CNS involvement, which often results in chronic disability. This review will outline the main clinical features of ECD, with emphasis on the emerging challenges in pathogenesis and management, and on the role of recent targeted approaches.

Extramedullary blast crisis of chronic myeloid leukemia in accelerated phase with pericardial and double upper limb soft tissue infiltration as the main manifestations: report of one case and review of literature

目的 探讨慢性粒细胞白血病（CML）加速期髓外急变（EBC）患者的诊治情况。 方法 报道1例以心包及双上肢软组织浸润为主要表现的CML-EBC，采用达沙替尼70 mg/次，2次/d治疗。 结果 治疗2周后患者双上肢肿胀完全消退。 结论 CML-EBC可发生在CML各阶段，以心包及双上肢软组织浸润为主要表现的CML加速期EBC临床极为罕见，达沙替尼治疗髓外浸润取得了较好的疗效。

Value of PET/MRI for assessing tumor resectability in NSCLC-intra-individual comparison with PET/CT.

The purpose of this study was to compare the diagnostic accuracy of positron emission tomography (PET)/MRI with PET/CT for determining tumor resectability of non-small cell lung cancer (NSCLC). Sequential trimodality PET/CT/MRI was performed in 36 patients referred with the clinical question of resectability assessment in NSCLC. PET/CT and PET/MR images including T1 weighted sequence (T1-Dixon) and respiration gated T2 weighted sequence (T2-Propeller) were evaluated for resectability-defining factors; i.e. longest diameter of the tumor, minimal tumor distance to the carina, mediastinal invasion, invasion of the carina, pleural infiltration, pericardial infiltration, diaphragm infiltration, presence of additional nodules. There was no significant difference of maximal axial diameter measurements of the primary lung tumors and narrow limits of agreement in Bland-Altman analysis ranging from -11.1 mm to + 11.8 mm for T2-Propeller and from -14.3 mm to + 13.8 mm for T1-Dixon sequence. A high agreement of PET/MR with PET/CT for the different resectability-defining factors was observed (k from 0.769 to 1.000). There was an excellent agreement of T2-Propeller sequence and CT for additional pulmonary nodule detection (k of 0.829 and 0.833), but only a moderate and good agreement using T1-Dixon sequence (k of 0.484 and 0.722). In NSCLC the use of PET/MRI, including a dedicated pulmonary MR imaging protocol, provides a comparable diagnostic value for determination of tumor resectability compared to PET/CT. Our findings suggest that whole body PET/MRI can safely be used for the local staging of NSCLC patients. Further studies are warranted to determine whether it is feasible to integrate an imaging sequence in a whole body PET/MRI setting with the potential advantage of detection of liver or brain metastases.

Pericardial effusion and congestive heart failure in a horse with multicentric lymphoma

A 20-year-old Warmblood mare was evaluated for acute-onset tachycardia and a one-week history of lethargy and ventral oedema. Haematology revealed leucocytosis with neutrophilia. Ultrasonographic examination revealed pericardial effusion and cardiac...

COMPARING THE TOXIC EFFECTS OF NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (CELECOXIB AND IBUPROFEN) ON HEART, LIVER, AND KIDNEY IN RATS

Objective: Nonsteroidal anti-inflammatory drugs (NSAIDs) do not reverse the disease progression, but they provide relief from pain and inflammation by inhibiting cyclooxygenase (COX) enzymes mediating the inflammatory pathway. Our aim was to make a meaningful comparison of both selective and non-selective COX-2 inhibitor to evaluate their toxic effects by measuring biochemical and histological alterations of heart, liver, and kidney.Methods: This study was conducted on 18 Sprague-Dawley rats of both sexes for 30 days, rats were divided into three groups (control group, ibuprofen group, and celecoxib group) each group included six rats.Results: The results are revealed that serum level of alanine aminotransferase, aspartate aminotransferase, alkaline phosphates, and total serum bilirubin was significantly increased (p&lt;0.05) in ibuprofen and celecoxib group when compared with control, the highest level in celecoxib group, also serum level of urea was significantly elevated (p&lt;0.05) in ibuprofen group when compared with control and celecoxib groups. Histopathological changes in cardiac tissue represented by vascular congestion and pericardial infiltration which are more prominent in celecoxib group, the changes in liver tissue revealed by vascular congestion and mild portal tract inflammation which is chronic in celecoxib group, while histological alterations in kidney tissue represented by severe vascular congestion with tubular necrosis which is more prominent in ibuprofen group.Conclusion: Both ibuprofen and celecoxib group have toxic effects on heart, liver, and kidney represented by the biochemical and histopathological findings.

Pericardial tumour infiltration of LV cavity in recurrence of previously treated lung adenocarcinoma

Pericardial tumour infiltration of LV cavity in recurrence of previously treated lung adenocarcinoma

Garcin syndrome caused by sphenoid bone metastasis of lung cancer: a case study

BackgroundGarcin syndrome, which consists of unilateral palsies of almost all cranial nerves without either sensory or motor long-tract disturbances or intracranial hypertension, can be caused by malignant tumors at the skull base. The case of a patient with lung cancer that metastasized to the sphenoid bone and resulted in Garcin syndrome is presented.Case presentationA 76-year-old woman was diagnosed as having non-small cell lung cancer with pericardial and diaphragmatic infiltration, cT4N1M0, stage 3A. The left lower lobectomy with concomitant resection of the pericardium and diaphragm was performed. The pathological diagnosis was pleomorphic carcinoma, pT2bN0M0, stage 1B. She was then followed in the surgery clinic, and 2 months after surgery, she visited an emergency room complaining of headache and diplopia. Neurological examination showed the left IV, V1, and VI cranial nerve palsies. Metastatic tumor with bone destruction was found in the left sphenoid sinus on head computed tomography (CT) and contrast magnetic resonance imaging (MRI), and she was diagnosed with Garcin syndrome caused by sphenoid bone metastasis of lung cancer. Irradiation was performed as palliative treatment, but her neurological findings did not improve. Her general condition gradually worsened, and she died 5 months after surgery.ConclusionsBone metastasis of lung cancer occurs frequently, but sphenoid bone metastasis is extremely rare. In this case report, Garcin syndrome caused by lung cancer is discussed in the context of the few previous reports.

Protocolo diagnóstico y tratamiento de la afectación pericárdica en las enfermedades neoplásicas

IntroductionThe diagnosis of pericardial disorder secondary to a neoplastic disease initially requires high diagnostic suspicion and then the systematic application of an aetiological study protocol. DiagnosisIf specific predictor factors for neoplastic disease are identified, drainage of pericardial fluid is recommended by percutaneous pericardiocentesis of heart surgery. Cytology of the pericardial fluid can establish pericardial neoplastic infiltration. However, occasionally a biopsy of the pericardium is required for anatomopathological study. TreatmentIf there is haemodynamic compromise, treatment will comprise drainage with emergency pericardiocentesis. Occasionally, staggered antineoplastic treatment is recommended, pericardiocentesis and intrapericardial instillation of cytotoxic or sclerosing agents. Percutaneous balloon pericardiotomy is a safe and effective procedure in the event of recurrent tamponade. In the advanced stages of the underlying neoplastic disease, the treatment of choice is palliative, exclusively to alleviate the patients’ symptoms.

Paragonimiasis: An Unexpected Cause of Cardiac Tamponade

SESSION TITLE: Lung Infections 2 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 30, 2017 at 11:00 AM - 12:00 PM INTRODUCTION: Paragonimiasis (lung fluke disease) is a potentially serious infection caused by lung fluke of the genus Paragonimus. It is endemic in Asia and Africa. In the United States (US), the disease is observed most frequently in immigrants from endemic countries, but local transmission has been described. CASE PRESENTATION: A 53 year- old man presented to an emergency department in the Mid-Atlantic United States complaining of a productive cough, shortness of breath, chest pain, abdominal bloating and diarrhea. A review of systems was notable for fatigue, weight loss and night sweats. His past medical history was significant only for hypertension. He grew up in East Africa and later immigrated to the US. He was afebrile, tachycardic and normotensive. Heart sounds were distant. A complete blood count showed a normal white cell count with normal eosinophil count. A comprehensive metabolic panel was normal. Stool was negative for ova and parasites. Chest radiography showed an enlarged heart. Computed tomography of the chest and abdomen showed a large pericardial effusion, small right pleural effusion, numerous small pulmonary nodules, and mass in the spleen (Figure 1). An echocardiogram showed signs of cardiac tamponade. The patient underwent urgent placement of a pericardial window. Pericardial fluid, pleural fluid and bronchoalveolar lavage were negative for bacteria, virus, acid fast bacilli, fungus and malignant cells. A transbronchial biopsy was non diagnostic. An open lung biopsy was performed, which revealed the presence of eggs consistent with Paragonimus. The patient was started on praziquantel after which his symptoms gradually resolved. DISCUSSION: Paragonimiasis may mimic a number of diseases, especially tuberculosis and neoplasm. Cough, hemoptysis, and pleural effusions are common. Diagnosis may require open lung biopsy. Pericardial infiltration, especially to the extent that cardiac tamponade develops, is quite rare. To our knowledge, this is the first reported case of paragonimiasis-induced cardiac tamponade in the US. CONCLUSIONS: Paragonimiasis is a rare cause of lung disease in the US. However, because of immigration from endemic areas and local spread of the disease, it is occasionally encountered in clinical practice. Because many clinical and radiographic abnormalities are non-specific, physicians must maintain a high index of suspicion. Reference #1: Gary Procop. North American Paragonimiasis. Clin Microbiol Rev. 2009 Jul; 22(3): 415-446 DISCLOSURE: The following authors have nothing to disclose: Abdalsamih Taeb, Joshua Sill No Product/Research Disclosure Information

Cardiac Myeloid Sarcoma: Multimodality Radiologic Imaging Features and Pathologic Correlation

Cardiac Myeloid Sarcoma: Multimodality Radiologic Imaging Features and Pathologic Correlation

"Bread and butter" fibrinous pericarditis.

Pericarditis is the inflammatory process involving the pericardium as a result of a systemic disease or a primary pericardium disorder.1 The actual incidence of pericarditis is difficult to ascertain,2 most probably because of under-reported or misdiagnosed cases. In the 19th century, Sir William Osler stated that pericarditis was one of the most serious diseases overlooked by practitioners.3 Even so, the rate of hospitalization by this diagnosis is estimated in 3.32 cases per 100,000 person-years, which corresponds to 0.2% of all causes of hospitalization in cardiology centers,4 with an incidence of 1.06% found in autopsy case series.5 Didactically, pericarditis can be morphologically classified in five types: (i) fibrinous; (ii) serous; (iii) purulent; (iv) hemorrhagic; or (v) caseous.6 The image presented herein refers to a typical fibrinous pericarditis, also known as “bread and butter” pericarditis.7 In such an entity, the pericardium, which is regularly smooth and bright, becomes opaque and granular, and macroscopically resembles two pieces of buttered bread pressed together then pulled apart. The histology shows the deposition of fibrin and leukocytic exudate involving the pericardial leaflets. 8 Antonio Benivieni (1443-1502), a Florentine physician and a contemporary of Leonardo da Vinci, was assigned the first description of fibrinous pericarditis. However, Rene Laennec (1781-1826), also known for creating the stethoscope, was the first to register the analogy of this type of pericarditis with “buttered bread”9 in his book, A Treatise on the Diseases of the Chest and on Mediate Auscultation.10 The image presented in Figure 1 was obtained during the autopsy of a 25-year-old man who presented a 5-day history of high-grade fever, odynophagia, chest pain, and bloody sputum. He was hospitalized presenting marked leukocytosis with blasts in the peripheral blood smear and died 14 days later due to multiple organ failure. The autopsy revealed fibrinous pericarditis with a brighter yellow exudate than usual (probably due to hyperbilirubinemia, with direct and indirect bilirubin levels of 4.61 mg/dL and 2.07 mg/dL, respectively), lungs with “beefy red consolidation” due to alveolar edema, hemorrhage, hyaline membrane, and diffuse neutrophilic infiltrate. The patient’s bone marrow was hypercellular at the expense of immature myeloid cells with areas of necrosis. The immunohistochemical study evidenced diffuse positivity for myeloperoxidase; CD117-positivity for 30% of the viable cells; CD34-positivity for 1% of the viable cells; and negativity for the terminal deoxynucleotidyl transferase–all of which were consistent with the diagnosis of M3 acute myeloid leukemia (French-American-British classification).11 Acute myocardial infarction, trauma/surgery, infection, uremia, systemic diseases, and neoplasia are among the most common causes of fibrinous pericarditis. Among the neoplasia, lung and breast malignancies stand out, followed by lymphomas and leukemia,12 although pericardial infiltration by nonlymphocytic leukemia is rarer.13 In a large case series of 420 postmortem examinations of the heart in acute leukemia,14 only 20 patients had symptoms of heart disease in life, and 9 of them had pericarditis at autopsy. In only 2 of the 9 patients, the pericarditis was the result of leukemic cell infiltrates into the pericardium; in 4 patients it was hemorrhagic; and in 2 it was pyogenic. Only 1 case remained with uncertain etiology, being fibrinous and unassociated with pericardial leukemic infiltrates, hemorrhages, or organisms, which also occurred in our case. The histopathologic study of the pericardium failed to reveal neoplastic cells, microorganisms, and viral inclusion; therefore, the precise etiology of the pericardial disease was not disclosed

Survival after surgical drainage of malignant pericardial effusion.

Management of malignant pericardial effusion (PE) is complex. Cardiac surgeons are not necessarily familiar with or are challenged by the many underlying etiologies. Analyzing risk factors for mortality may help to estimate the benefit of surgery in high-risk patients. Patients undergoing a surgical pericardiotomy for malignant PE, between 2001 and 2011, were included. The influence of tumor type, disease extension, intra-pericardial tumor infiltration on early mortality and long-term survival as well as freedom from symptoms after drainage, and the use of sclerosing agents on PE recurrence rates was analyzed. PE drainage was performed on 46 patients 12 ± 30 months after tumor diagnosis. Malignant diseases were lung cancers (50 %), breast cancers (15 %), lymphoma and leukemia (13 %), cancers of the digestive tract (13 %), and others (9 %). 80 % of patients were symptomatic and symptom relief was achieved in 65 %. Nobody died during surgery. Recurrence rate was 4 %. Early in-hospital mortality was 22 %. After 1 year, 29 % of patients were alive. Eleven patients (24 %) had a complete tumor regression. Metastatic spread (p < 0.001), pericardial infiltration (p = 0.02), and intra-pericardial Bleomycin (p = 0.01) injection were associated with increased mortality. Hematological malignancies had a better prognosis for survival. Surgical pericardiotomy is safe, associated with a low recurrence rate and symptom relief in the majority of dyspneic patients. Intra-pericardial Bleomycin may reduce recurrent effusion but does not ameliorate survival. Long-term survival rate was low with an increased mortality in cases of metastatic spreading, pericardial infiltration, and as the tumor of origin: breast cancers. Leukemic and lymphatic tumors have better prognosis.

18F-FDG PET-CT for Evaluation of Cardiac Angiosarcoma: A Case Report and Review of Literature.

Cardiac angiosarcomas are rare neoplasms. We here present the case of a 24 year old male with a cardiac mass which was characterised as malignant on 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET-CT). In addition 18F-FDG PET-CT also demonstrated pericardial infiltration and bone metastases. The tumor was confirmed to be angiosarcoma on biopsy and palliative chemotherapy was started. Here we have highlighted the potential role of 18F-FDG PET-CT in patients with cardiac angiosarcoma and presented a brief review.