Signs Of Cardiac Tamponade Research Articles

SPONTANEOUS CHILOPERICARD IN PEDIATRIC AGE IS THERE AN IDEAL MANAGEMENT ALGORITHM?

Introduction: Chylopericardium is the presence of chylous fluid in the pericardial space. The most frequent causes of this rare entity are secondary to surgery and other invasive techniques on the thorax, followed by idiopathic ones, although they have also been associated with congenital anomalies of the lymphatic system, lymphangiomas and other mediastinal tumors, tuberculosis, etc. Its appearance is more common in adults, but lately cases have been described equally between the pediatric population and adults. Cases Reports: The presence of two patients of 8 and 11 months of age who present with significant amount of fluid at the level of the pericardium with involvement of right cardiac chambers in whom the pericardiocentesis performed reveals chyle without a frank pathological association is reported. Different managements with a single purpose, to achieve the ideal treatments for each case. Results: Two patients were identified from our surgical registry in the period described. The first corresponded to a male, of 11 months of age, without significant antecedents, with evidence of chylous pericardial effusion of spontaneous appearance that did not yield to the established conservative measures and later went to surgery for ligation of the thoracic duct and partial pericardiectomy. The second is a patient recently evaluated in the area of pediatrics, male, of 8 months, with Down Syndrome who comes to emergency of our hospital due to the presence of dyspnea, general malaise and food intolerance. The chest X-ray revealed the presence of cardiomegaly and a complementary transthoracic echocardiogram revealed severe pericardial effusion with signs of cardiac tamponade. Diagnostic and evacuation pericardiocentesis was performed with a pediatric central catheter, obtaining serous fluid and draining 35 cc, but three days after the puncture, the exit of chylous fluid through the catheter maintained in the pericardial space was observed. Conservative management is conditioned for a period of 7 days. The rest of the literature review identifies 18 pediatric patients with the presence of a spontaneously occurring pericardial effusion with different treatments offered. Discussion and Conclusions: Chylopericardium is a pathology of rare appearance, the main etiologies define patients who have been taken to cardiac or thoracic surgery. The most categorical description is given for adulthood but in the pediatric age (under 18 years) has not been described a consensus management yet for the variability of its diagnosis, however management remains uncertain after its appearance in those who debuted with primary chylopericardium or spontaneous origin, but despite this the implementation of conservative measures such as enteral nutrition with fatty acids of each media and use of parenteral nutrition between 7 to 15 days; and after the failure of these measures, surgery with thoracic duct ligation by right thoracotomy plus pleuropericardial window confection or partial pericardiectomy are the most successful management options that are known to date with good results in the short and medium term.

Erdheim-Chester Disease: A Rare Clinical Entity.

Erdheim-Chester disease is a non-Langerhans cell histiocytosis that affects multiple organs and systems.Thorough study of a pericardial effusion is important as it is still considered idiopathic in 10-20% of cases.It is a rare disease so high diagnostic suspicion is important. The diagnosis is established through clinical manifestations, radiologic findings and histological confirmation.

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

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

A Floating Heart: Large Pericardial Effusion with Extensive Lung Atelectasis

In extraordinary circumstances, large pericardial effusions cause pulmonary atelectasis (Amin et al., Cureus 11:e5287, 2019; Manhas and Gokhale, Indian J Crit Care Med 22: 191–194, 2018). Fluid builds up slowly and enlarges the pericardial sac, which can then compress the lung with minimal hemodynamic consequences. However, these patients are at risk of life-threatening tamponade. A morbidly obese 57-year-old man presented for mild chest pain and shortness of breath developed within several days. His medical history included an episode of idiopathic acute pericarditis, recurrent atrial fibrillation-flutter, and obstructive sleep apnea syndrome. There were no definite signs of cardiac tamponade. At first, the chest radiograph suggested a large effusion, which the computed tomography (CT) scans revealed to be the heart ‘floating’ within a large pericardial sac, together with extensive atelectasis. Considering the hazard of puncturing the heart, an intercostal catheter was inserted under Visiport optical guidance. An ultrasound-guided pericardiocentesis completed the procedure, draining 1.6 l of blood-stained fluid in total. The floating heart, coupled with extensive atelectasis, poses a therapeutic challenge. This case shows that an optical trocar allows for controlled drainage, thus reversing both the effusion and the atelectasis.

P1339 Clinical masks of aortic aneurysm: staged rupture of an aortic aneurysm under the guise of a recurrent infection

Abstract A 63-year-old man was admitted to the medical intensive care unit because of hypotension and suspected sepsis. Two months before he was admitted to military hospital for cerebrovascular event, considered as transient ischemic attack. Few days after discharge the fever (with a temperature of 39.5°C) occurred and patient was readmitted to the same hospital. Empirical treatment with cefalosporine was inefficient. Only combination carbapenem and vancomycin after E.coli was verified in blood culture stopped the infection. With normal body temperature, normal leukocytes count, mild azotemia, sterile blood and urine cultures and diagnosis of treated urosepsis patient was discharged. Two echocardiogram during hospital stay found no abnormal findings and chest CT scan was also normal. Seven days later, he was seen in our hospital because of fever (with a temperature of 40°C), severe sweating and arterial hypotension. Immediately fluids and norepinephrine infusion was started. Fluoroquinolone was chosen as an antibiotic. There was complete LBBB on ECG that had been registered previously. Leucocyte count at admission was 14 x 109/l and creatinine 300 µmol/l. Transthoracic echo (TTE) reportedly showed evidence of mild aortic and mitral regurgitations, pericardial effusion (1.0 – 1.3 cm with signs of right atrium compression). Aortic root seemed quite normal. On the third day, the number of leukocytes and creatinine increased significantly, reaching 450 µmol/l and 41 x 109/l respectively. Chest CT scan revealed signs of bilateral pneumonia, pericardial and left-sided pleural effusions. Vancomycin and ceftriaxone intravenously were started. Transesophageal echo revealed degenerative changes of aortic valve with mild insufficiency, mild mitral regurgitation. The amount of fluid in the pericardium was approximately unchanged. Patient became normotensive and norepinephrine infusion was discontinued. On the 6th day after admission patient’s temperature became normal, level of creatinine decreased to 230 µkmol/l and leukocytes reached 11.4 x 109/l. On the same day, the patient"s condition worsened. He complained of mild heartburn and progressive weakness, the number of leukocytes and the activity of transaminases increased, his blood pressure dropped to 75/40 mm Hg. This has led to the resumption of norepinephrine infusion. Repeated CT scan revealed inhomogeneous contents in the pericardium. Repeated TTE found increase of pericardial effusion with heterogenous content and signs of cardiac tamponade. Patient was transferred to operating room. After pericardiotomy multiple blood clots and active bleeding from pseudoaneurysm of ascending aorta were found. Despite surgical attempts and massive transfusion, patient died. Autopsy revealed the rupture of pseudoaneurysm of ascending aorta and flat hematoma in pericardium. Abstract P1339 Figure.

1101 Multimodality imaging in the assessment of pericardial malign disease

Abstract Metastases to the heart and pericardium are discovered at autopsy in 10%–12% of all patients with malignancies. The most common primary tumor involving the pericardium is lung cancer, followed by breast, melanoma, and lymphoma. Pericardial effusion may be the result of the tumor spreading to the visceral pericardium which increases production of fluid, or accumulation of the fluid due to the obstruction of venous and lymphatic outflow. A malignant pericardial effusion is associated with decreased survival rate. We present a 72 year-old woman, former smoker with dyslipidemia and psoriatic arthritis as well as previous bladder carcinoma that was healed in 1986. On august 2017 after an acute intestinal obstruction she was diagnosed with stage IV ileum adenocarcinoma treated initially with palliative chemotherapy (Capecitabine and oxaliplatin) that was suspended for poor tolerance and according to patient desire. Few months later the patient complained of rapidly progressive dyspnoea that prevented her normal life activity, arterial pressure and blood oxygen saturation was normal, but she was tachycardic. Echocardiogram was performed (see figure) which showed marked pericardial nodular thickening and severe pericardial effusion with echocardiographic signs of cardiac tamponade. Curiously, pericardial effusion was dense and markedly hyperechogenic. A computed tomography (CT) was performed to rule out pericardial carcinomatosis and find out the pericardial fluid composition and demostrated several pericardial nodular thickenings that suggested metastases. The pericardial fluid was dense (40 hounsfield units) and consistent with blood. After multidispiplinar consultation and in accordance with patients wishes a palliative pericardial window was performed and hematic pericardial fluid was obtained. Pericardial liquid citology demonstrates atipical cells compatible with carcinoma and pericardial biospy showed fibrinous pericarditis and reactive mesothelial hyperplasia. Pericardial carcinomatosis consists of macroscopic or microscopic affection of pericardial layers. Metastasis from colorectal cancer to the pericardium is uncommon, and usually indicates terminal stage with multiple metastases, only a few cases have been reported. Malignant Pericardial effusions in patients with cancer may also be triggered by other mechanism than cancer itself, including chemotherapy, radiation therapy, and, less commonly, an infectious disease. Whereas echocardiography is most frequently used to examine the heart and pericardium, multimodaliy imaging with magnetic resonance (MR) or/and CT offer advantages when dealing with metastatic disease. Abstract 1101 Figure. Echocardiogram and CT images

Bacterial Pericarditis Causing Cardiac Tamponade in a Patient with No Primary Source of Infection

Introduction Bacterial Pericarditis is a rare entity accounting for Case Description 73 year old male with history of coronary artery disease presents with pleuritic chest pain and dyspnea since 2 days. On arrival, he was hemodynamically stable. EKG showed changes consistent with acute pericarditis. Echo showed moderate pericardial effusion without tamponade and normal systolic/diastolic function. Patient was treated with colchicine, NSAIDS could not be given due to acute kidney injury. His home dose of aspirin and clopidogrel were continued. Overnight, patient decompensated with persistent tachycardia, tachypnea and hypoxia. He started spiking fevers with worsening leucocytosis. Echo showed moderate pericardial effusion with signs of cardiac tamponade. Urgent pericardiocentesis was done and 250 mL of serosanguinous fluid was removed and a pigtail catheter was left in situ. His antiplatelet agents were discontinued to prevent hemorrhagic pericardial effusion. Methicillin sensitive Staphylococcus aureus was detected in cultures of pericardial fluid and blood. His antibiotic was deescalated to intravenous nafcillin. Echo post procedure showed small pericardial effusion with fibrinous echogenic material. His pericardial drain was not draining enough and was removed the next day. He started developing moderate left sided pleural effusion, likely an extension of pericardial inflammation. A small bore pleural catheter was placed in left pleural space for drainage. He had to undergo pericardectomy for definitive drainage and a chest tube was placed in right pleural cavity for drainage. Transesophageal echocardiogram demonstrated no further pathology. Repeat echo and CT-chest did not show any effusions, so pleural drains were removed on 6th day and patient was doing well. Discussion Purulent pericarditis presents as an acute illness characterized by fever in all patients, chest pain in 25-37% of patients. Bacterial pericarditis is usually not a primary infection, but occurs as a complication of underlying infection. Risk factors are immunosuppression, chest injuries, and chronic kidney disease with hemodialysis, diabetes mellitus and alcoholism. About 15% of patients with purulent pericarditis can develop cardiac tamponade. Typically small effusions accumulate quickly and develop tamponade. Large effusions can accumulate slowly allowing the pericardial sac to expand. Treatment is drainage of pus along with antibiotic therapy. Pericardiocentesis may be sufficient but in case of recurrent effusion or poor drainage of thick loculated fluid, pericardiotomy and pericardial window with manual lysis of adhesions and loculations allowing complete drainage is required. Survival in purulent pericarditis depends on early empiric antibiotic therapy and pericardial drainage.

An Unusual Presentation of Tuberculosis

The normal pericardium is a fibroelastic sac containing a thin layer of fluid that surrounds the heart. Cardiac tamponade, which may be acute or subacute, is characterized by the accumulation of pericardial fluid under pressure. Tuberculous pericarditis is a complication of tuberculosis which is often diagnose late due to the difficulty in establishing this diagnosis. We present a case of pericardial tuberculosis diagnosed in a 20-year-old young retroviral disease patient who presented with signs of cardiac tamponade. His clinical condition improved post-pericardial tapping and he was discharged with antituberculosis medications. This case highlight the importance of having a high level of suspicion as this condition is easily curable.

WITHDRAWN: Spontaneous Resolution of Pericardial Effusion in an Elderly Related to Monopolar Radiofrequency Ablation for Hepatocellular Carcinoma

Summary Hepatocellular carcinoma (HCC) is a leading cause of cancer in the world. The incidence is increasing by age. Radiofrequency ablation (RFA) is widely used for treatment of HCC especially for those in early stage. RFA have some advantages compare to surgery including lower cost, shorter hospital day and lower complication rate. However, there's still some rare but lethal RFA associated adverse events including cardiovascular complication. We hereby reported an elderly patient with HCC in left liver abutting the right atrium. The patient received monopolar RFA for treating HCC and had experienced pericardial effusion during RFA without immediate signs of cardiac tamponade. The HCC was successfully ablated without local recurrence and the pericardial effusion was spontaneously resolved without sequelae.

Purulent pericarditis and Pasteurella multocida: An extremely rare combination

Abstract Purulent pericarditis is a rare entity, defined as the presence of neutrophilic pericardial effusion which is infected by a bacterial, fungus or parasite agent. The diagnosis can be challenging, especially if patients have taken previous antibiotic therapy; on the other hand the recognition of this pathology is often made late, with the onset of severe symptoms or signs of cardiac tamponade or even only at the autopsy. The authors describe the case of a 82-year-old woman with history of extensive laceration of the right lower limb from a dog bite in July 2016, admitted to the Cardiology Department one month later for Acute Pericarditis. During hospitalization she maintained recurrent fever peaks despite the treatment with non-steroidal anti-inflammatory drugs and colchicine. She collected blood cultures and repeated echocardiogram showed increased pericardial effusion with no signs of hemodynamic compromise. Blood cultures revealed the presence of Pasteurella multocida. Due to clinical suspicion of purulent pericarditis, pericardiocentesis was performed with drainage of liquid compatible with exudate and the patient was presented to the Cardiothoracic Surgery Department for pericardiotomy and adequate drainage of the liquid. Histological examination confirmed the diagnosis of Acute Pericarditis. It should be noted that Pasteurella is a very frequent agent (50-90%) in the gastrointestinal tract and nasopharynx of many domestic animals, namely dogs. The authors emphasize the need to aggressively treat this pathology, since untreated death is inevitable.

Cardiac tamponade as a manifestation of extrapulmonary tuberculosis in β thalassemia major patient

Cardiac tamponade is a medical emergency condition. Rapid diagnosis and determination of the etiology with epidemiologic consideration may lead to earlier treatment and improved survival. Occasionally, the etiology may be clearly related to a recognized underlying disease, but the possibility of unrelated etiologies should be considered. Pericarditis tuberculosis, a rare manifestation of extrapulmonary tuberculosis in a non-HIV patient, has to be deliberate as one of the etiology, especially in the endemic area. Here, we report a case of 28 years old male with β thalassemia major presented with excessive exertion breathlessness progressing to orthopnea. Sign of cardiac tamponade was identified from echocardiography which showed large pericardial effusion with swinging heart and right atrial systolic collapse. Pericardiocentesis was performed immediately, drained 870 ml of hemorrhagic fluid from inserted pigtail. The patient was treated with the anti-tuberculosis regimen and oral corticosteroid after real-time polymerase chain reaction of Mycobacterium tuberculosis positivity in pericardial fluid. MRI T2 confirmed no haemosiderosis in patient’s heart. After treatment, the patient responded well and showed clinical improvement.

Derrame pericárdico maligno secundario a adenocarcinoma de pulmón: Reporte de caso

Introducción: El derrame pericárdico maligno es la acumulación de líquido en el espacio pericárdico secundario a neoplasias en estadios avanzados, siendo así, un indicador de mal pronóstico. Los tumores malignos que con mayor frecuencia se relacionan con esta entidad son los de origen pulmonar, mamario y hematolinfoides. Clínicamente puede cursar con signos inminentes de taponamiento cardiaco e inestabilidad hemodinámica, por lo que amerita un diagnóstico temprano y manejo urgente con maniobras de descompresión. Objetivo: Este articulo busca presentar un caso de derrame pericárdico maligno, debido a que esta condición clínica implica un reto diagnóstico. Presentación del caso y conclusiones: Presentamos el caso de un paciente masculino de 63 años de edad, con cuadro clínico de 1 mes de evolución, caracterizado por presencia de adenopatías cervicales, quien en los últimos 15 días presenta saciedad precoz, sudoración nocturna, sensación de distensión abdominal y deterioro de la clase funcional hasta disnea de pequeños esfuerzos, motivo por el cual consulta al servicio de urgencias. Durante la observación médica rápidamente progresa a inestabilidad hemodinámica, refractaria a manejo; se realizan estudios imagenológicos, en donde se evidencia derrame pericárdico severo, por lo que se procede a realizar pericardiocentesis descompresiva emergente y manejo integral multidisciplinario.

Pericardial Synovial Sarcoma presenting with Cardiac Tamponade

ABSTRACTPericardial synovial sarcomas are very rare and usually associated with poor prognosis if not diagnosed and treated early. It usually presents with symptoms of a massive pericardial effusion and signs of cardiac tamponade and failure. Here, we report the case of a 27-year-old patient with exertional dyspnea and massive pericardial effusion. Echocardiography and magnetic resonance imaging revealed a pericardial mass. The patient was treated by surgical excision and a subsequent histological analysis confirmed the diagnosis of pericardial synovial sarcoma.How to cite this articleShetty R, Hiremath S. Pericardial Synovial Sarcoma presenting with Cardiac Tamponade. J Med Sci 2017;3(1):28-30.

Incidence and factors associated with pericardial effusion after cardiac valve surgery

Introduction: Pericardial effusion (PE) is a postoperative complication of cardiac valve surgery, related to early hospital readmissions and death. We aimed to describe its incidence and to identify predictive factors of moderate-to-severe PE in a contemporary cohort. Methods: We retrospectively reviewed medical records of all consecutive patients submitted to cardiac valve surgery in a tertiary teaching hospital from January 2012 to July 2014, where echocardiography was routinely performed before patient discharge. Moderate-to-severe PE was defined as ≥ 10 mm of thickness, or signs of cardiac tamponade on echocardiography. Additional clinical and perioperative data were extracted from medical records using a standardized protocol. Results: Of 353 patients, 335 underwent a predischarge echocardiography. From these, 27 patients (8%; mean age: 62 years; standard deviation 12 years; 70% male) had moderate-to-severe PE. These patients had a higher prevalence of previous stroke (22% vs. 8%; p = 0.009) and oral anticoagulation (international normalized ratio > 2) prior to the surgery (11 vs. 2%; P = 0.002). In patients with moderate-to-severe PE, surgeries had longer ischemia (p < 0.001) and cardiopulmonary bypass (p < 0.001) times, and the prevalence of postoperative atrial fibrillation was higher (56% vs. 32%; p = 0.011) than in patients with absent or small PE. Hospital mortality was also higher (15% vs. 3%; p = 0.002) in patients with moderate-to-severe PE. Conclusions: Eight percent of patients submitted to cardiac valve surgery developed moderate-to-severe PE. Moreover, PE was associated with pre- and post-surgery conditions likely related to the coagulation state, though a cause-effect relationship could not be inferred. Noteworthy, this condition was associated with higher in-hospital morbidity and mortality. Keywords: Adult; pericardium; postoperative care

Invasive meningococcal disease with pericarditis and pneumonia: A rare presentation in childhood

Previously healthy 2-year-old boy presented with a 3-day history of fever, irritability and vomiting. There was no cutaneous rash. Ceftriaxone (100 mg/kg/day) and Dexamethasone 5.5 mg 6/6 h (on the first 3 days) were started and lumbar puncture was performed. Cerebral spinal fluid (CSF) showed 3.696 WBCs/μL with 99% neutrophils, glucose 1 mg/dL and total protein 578.0 mg/dL. CSF Gram stain showed extracellular and intracellular Gram-negative diplococci. Latex agglutination was reactive for N. meningitidis group C. The CSF culture was negative. After 6-day of antibiotic treatment patient started with dyspnea, dry cough and hypotension. Cardiorespiratory examination revealed an elevated jugular venous pressure, normal heart sounds, with no pericardial rub, coarse sounds with crackles over left base were heard. New CSF analyses showed 336 WBCs/μL with 61% neutrophils, 39% lymphocytes, protein 99.5 g/L and glucose 26 mg/dL (serum glucose 75 mg/dL). The CSF and blood cultures were negative. Chest X-ray showed an enlarged cardiac silhouette, consolidation in the left lung and pleural effusion. The antimicrobial treatment was changed to meropenem. Computed tomography of the chest showed moderate pleural effusion, consolidation in the left lobe. The cardiac echography revealed a pericardial effusion. There was no sign of imminent cardiac tamponade. Pericardiocentesis was performed and a total of 115 ml hemorrhagic pericardial fluid was aspirated. The fluid analysis demonstrated 1.460 WBC/mm3, with 85% polymorphonuclear neutrophils and 15% lymphocytes, total proteins of 4.5 g/dL, 836 U/L LDH and glucose 60 mg/dL. No microorganism was observed by Gram and Ziehl-Nielsen stain. The pericardial fluid culture to aerobic and mycobacteria was negative. Methylprednisolone was administered for five days. Patient was discharged after 14 days of antibiotic therapy with full recovery. We present a case of meningococcal meningitis that developed two rare manifestations associated in children: pericarditis and pneumonia (Fig. 1, Fig. 2, Fig. 3). Occurrence of cardiac tamponade in reactive pericarditis is most often associated in serogroup C infections [1], [2], serogroup predominant in Amazon [3]. Meningococcal pneumonia is more associated with serogroup Y [4]. The forms of presentation of pericardial involvement include: disseminated meningococcal infection with pericardial, primary meningococcal pericarditis and reactive meningococcal pericarditis [1]. The hypersensitivity reaction type 3 tends to occur during the convalescent period (4–10 days after the start of antibiotic therapy) [5]. Thought to be due to a hypersensitivity reaction to previously damaged pericardial tissue, which acts as an antigen stimulus to antibody formation [5]. If the effusion is large treatment is done with high doses corticoids [1]. Fig. 1 Chest X-ray showed an enlarged cardiac silhouette, consolidation in the inferior lobe of left lung and pleural effusion. Fig. 2 Computed tomography of the chest (CTC) showed left lung atelectasis, moderate pleural effusion and consolidation in the left upper lobe. CTC mediastinal window shows moderate pericardial effusion. Fig. 3 The cardiac echography revealed a pericardial effusion. There was no sign of cardiac tamponade.

Bedside Echocardiographically Guided Pericardiocentesis for Cardiac Tamponade after Coronary Artery Injury Secondary to Percutaneous Coronary Intervention: A Case Report and Descriptive Technique

Given over 2.64 million total percutaneous coronary interventions performed in the United States, and that acute cardiac tamponade is one of the most common complications of such percutaneous coronary interventions, clinicians should be familiar with diagnosing impending pericardial tamponade, and a simple and safe bedside technique for drainage. We describe a technique for echocardiographically guided rescue pericardiocentesis in the setting of acute tamponade to demonstrate the efficacy and safety of this technique for pericardial drainage with reduced complication risk as compared to a landmark-based approach. A case of a 52-year-old male was brought to the Emergency Department after a witnessed cardiac arrest. He underwent cardiac catheterization and percutaneous coronary stent implantation. Thirty minutes after stenting, the patient developed signs of cardiac tamponade, and point-of-care echocardiogram confirmed a pericardial effusion. An in-plane ultrasound-guided pericardiocentesis was successfully performed by the junior house-staff under direct attending supervision. Serial echocardiograms demonstrated preserved left ventricular systolic function without new effusion. The patient remained hemodynamically stable for 48 hrs following the procedure at which time the pericardial catheter was removed. Ultrasound image guided pericardiocentesis is a rapid and safe technique for pericardial drainage with reduced complication risk as compared to a landmark-based approach.

Pneumonia and Purulent Pericarditis Caused by Streptococcus pneumoniae

Bacterial pericarditis in children has become a rare entity in the modern antibiotic era. The most common pathogen is Staphylococcus aureus, being Streptococcus pneumoniae an exceptional cause. We present 2 children, who were diagnosed of pneumonia complicated with a pleural effusion that developed a purulent pericarditis with signs of cardiac tamponade. One of them had received 4 doses of the 7-valent conjugated pneumococcal vaccine. Systemic antibiotics and pericardial and pleural drainages were used. Pneumococcal antigens were positive in pleural and pericardial fluids in both cases, and S. pneumoniae was isolated from pleural effusion in one of them. Both children fully recovered, and none of them developed constrictive pericarditis, although 1 case presented a transient secondary left ventricular dysfunction. Routine immunization with 10- and 13-valent vaccines including a wider range of serotypes should further decrease the already low incidence.

A case of primary effusion lymphoma diagnosed by open cardiocentesis

Primary effusion lymphoma is a type of B-cell lymphoma that is primarily related to human immunodeficiency virus. Thoracic surgeons rarely encounter this disease because of its rarity. We herein report a case of primary effusion lymphoma which required surgery for successful treatment. An 83-year-old man was admitted to our hospital with signs of cardiac tamponade. A radiological examination revealed a pericardial effusion. Performing percutaneous pericardiocentesis was difficult due to the patient's anatomical features. We performed open cardiocentesis under general anesthesia. A cytologic examination revealed primary effusion lymphoma. The patient underwent chemotherapy, resulting in complete remission.

Multiple Complex Penetrating Cardiac Injuries: Role of Civilian Trauma in the Education of the Combat General Surgeon

To use a case report of a complex cardiac injury case to illustrate how civilian trauma can be used to train combat general surgeons. We report the case of a 23-year-old man who suffered three penetrating injuries to the left ventricle (LV) after multiple stab wounds to left chest. On hospital arrival he was conversant, hemodynamically stable, oxygenating well, and without signs of cardiac tamponade. He deteriorated and required an urgent exploratory thoracotomy. Intraoperatively, 2-, 3.5-, and 5-cm stellate lacerations were discovered in the LV near the aortic root, of which, two were full thickness. A simple pledgeted horizontal mattress suture was not sufficient to repair the injuries. The repair ultimately required a running polypropylene suture to control the hemorrhage. The patient was awake on postoperative day 0 and discharged on postoperative day 12 without significant complication. This case illustrates several points for the combat surgeon. First, young men are able to tolerate catastrophic injuries, presenting with normal hemodynamics. Second, there are a variety of techniques to use when treating uncommon injuries. Finally, the surgeon needs the ability to improvise quickly and to apply surgical techniques to treat complex traumatic injuries successfully.

Chylopericardium with cardiac tamponade secondary to acute Epstein-Barr virus peri-myocarditis

A 20-year-old man, with no medical history, was referred to the emergency ward because of severe shortness of breath. Heteroanamnesis revealed that he had suffered influenza-like symptoms for a week, which had become worse in the last 24 h. Physical examination showed a critically ill patient with high fever (body temperature 40°C), tachycardia (pulse rate 110/min), tachypnoea (respiratory rate 35/min), hypotension (RR 100/60 mmHg), and elevated jugular venous pressure; on auscultation diffuse pulmonary crackles were heard. In addition there was a low peripheral oxygen saturation (85 %). Electrocardiography showed sinus tachycardia, with a low voltage of the QRS complex in the limb leads, but was otherwise normal. Meanwhile, the patient’s condition deteriorated which made a transfer to the intensive care unit (ICU) necessary with subsequent invasive mechanical ventilation and treatment with inotropic agents. Also broad-spectrum antibiotics were given, because severe pneumonia was suspected. The main laboratory blood tests revealed a white blood cell count (50× 10/l), CRP (489 mmol/l) and liver enzymes (aspartate aminotransferase/alanine aminotransferase 47/61 U/l, gamma-glutamyl transpeptidase 219 U/l, and alkaline phosphatase 159 U/l) with a disturbed renal function (creatinine 139 μmol/l, glomerular filtration rate MDRD: 57 ml/min/1.73 m, and urea 10.4 mmol/l). At chest X-ray the right lung base showed an air bronchogram with increased attenuation in the right lung base consistent with consolidation. In addition, diffuse bronchial interstitial oedema and cardiac enlargement were present (Fig. 1). Because of these findings, transthoracic echocardiography was performed, showing severe impairment of left ventricular function and pericardial effusion with signs of cardiac tamponade (Fig. 2). Therefore, the patient underwent pericardiocentesis and 800 cc of non-viscous milky fluid was evacuated, immediately leading to haemodynamic improvement. This fluid, which was initially regarded as purulent fluid, turned out to be chyle, because analysis revealed a high concentration of triglycerides and a cholesterol-triglyceride ratio <1. Bacterial analysis of both blood and pericardial fluid (chyle) by culture and broad range polymerase chain reaction analysis (PCR) on various viral pathogens was negative, except for the PCR on Epstein-Barr virus (EBV), which was positive with a higher viral load in the pericardial chyle than in the peripheral blood. Serological analysis suggested a previous EBV infection or a reactivation of the virus, which had caused perimyocarditis, because viral capsid antigen (VCA) IgG and Epstein-Barr nuclear antigen (EBNA) IgG were positive, but VCA IgM remained negative. D. A. A. M. Schellings :M. F. Boomsma :M. J. H. M. Wolfhagen : M. Hijmering :A. R. Ramdat Misier Isala Clinics, Thorax Centre, Zwolle, the Netherlands