Small Pericardial Effusion Research Articles

Prevalence of cardiovascular manifestations in patients with hypermobile Ehlers-Danlos syndrome at the University of Miami.

Cardiovascular system involvements have been frequently reported in hypermobile Ehlers-Danlos Syndrome (hEDS). Mitral valve prolapse (MVP) and aortic root dilatation are included in the 2017 international classification criteria for hEDS. Different studies have found conflicting results regarding the significance of cardiac involvement in hEDS patients. We conducted a retrospective review of cardiac involvement in patients diagnosed with hEDS based on the 2017 International diagnostic criteria to provide further evidence toward more defined and reliable diagnostic criteria and recommended cardiac surveillance. A total of 75 hEDS patients with at least one diagnostic cardiac evaluation were included in the study. The most common reported cardiovascular complaints were lightheadedness (80.6%), followed by palpitations (77.6%), fainting (44.8%), and chest pain (32.8%). Of the 62 echocardiogram reports, 57 (91.9%) showed trace/trivial to mild valvular insufficiency, and 13 (21%) had additional abnormalities such as grade I diastolic dysfunction, mild aortic sclerosis, and trivial or small pericardial effusion. Of the 60 electrocardiograms (ECG) reports, 39 (65%) were normal, and 21 (35%) reported minor abnormalities or normal variants. Even though many hEDS patients in our cohort experienced cardiac symptoms, the presence of a significant cardiac abnormality was very low.

Late complications of the new coronavirus infection: a clinical case

According to the literature, exudative pleurisy and pericarditis are considered rare complications of the new coronavirus infection. This estimation can be explained by the fact that statistical studies cover mainly the hospital treatment of this disease. The true frequency of these complications and their consequences are not fully understood.Aim. The study of late complications of the new coronavirus infection in the form of pleurisy and pericarditis.Conclusion. In our case, a 62-year-old patient with the new coronavirus infection confirmed by polymerase chain reaction, severe bilateral polysegmental viral pneumonia, CT3, 60% on day 43 after the onset of clinical symptoms, was found to have manifestations of pleurisy and pericarditis during outpatient treatment. Cardiac MRI is the most informative method for detecting small pericardial and pleural effusions. The diagnostic capabilities of this method are superior to ultrasounography of the heart and pleural cavities and computed tomography of the lungs. Administration of colchicine 1.0 g per day for 1 month allowed not only to the elimination of pericarditis and pleurisy, but also the reduction of pressure in the right ventricle, probably by reducing the damage to the pulmonary parenchyma.

Woman With Chest Pain and Dyspnea

A 48-year-old woman presented to the emergency department with 1 day of chest discomfort, dyspnea, and orthopnea. She was discharged from the hospital 2 days ago after radiofrequency catheter ablation for atrial flutter. Her ECG and chest radiography were both normal. Bedside cardiac point-of-care ultrasound showed a large hyperechoic mass in the left atrium (Figure 1, Figure 2, Videos E1 and E2).Figure 2Ultrasonographic apical view demonstrated the hyperechoic mass (arrowhead) occupying most of the left atrial cavity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Left atrial intramural hematoma post–catheter ablation. Cardiac computed tomography (CT) demonstrated a left atrial intramural hematoma causing compression of the left ventricular inflow tract with a small pericardial effusion (Figure 3). The patient was admitted to the coronary care unit for monitoring and observation; at 4 days, her repeat cardiac CT demonstrated a stable hematoma, and she was discharged after 7 days. At 1 month, her cardiac CT later showed nearly complete resolution. The overall incidence of ablation-related complications has been decreasing over the last few decades as institutions have gained experience and is estimated at 3% although the incidence of left intramural hematoma is far lower.1Gupta A. Perera T. Ganesan A. et al.Complications of catheter ablation of atrial fibrillation: a systematic review.Circ Arrhythm Electrophysiol. 2013; 6: 1082-1088Crossref PubMed Scopus (188) Google Scholar, 2Giudicatti L. King B. Lee F. et al.Left atrial intramural hematoma post-ablation of supraventricular tachycardia: a rare complication treated successfully.JACC Case Rep. 2020; 2: 223-226Crossref PubMed Scopus (2) Google Scholar, 3Haseeb S. Kutyifa V. Left atrial intramural hematoma after radiofrequency catheter ablation: beware of the unexpected.JACC Case Rep. 2020; 2: 227-229Crossref PubMed Scopus (2) Google Scholar Bedside ultrasound is an excellent method to ascertain cardiac and pericardial complications. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxMGNkZTUyZjdjMGJhYWUzMjQ5MGM5NGJjYTYzYjBhNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1NzYwNTA0fQ.O-IwG7CyTItrbzjRokj7gIU1Hzxu7dNLt3ApgNoAp9vDpBMfLbEKgpWSk8sYHetH5Vz8WHXqbQ2Cb5ss4AUxggfsnbvgk0JbJyfkCH7qyJs_mP-wTCLwzS1Q24JLTBWQzQVzmb3YjKPAXSYRppC7irO7R1G0L9eWvgTh4CYPzGjHjYnv2SZGDAMs0B5-rwKF39aZX7nFRt2qVGQ1gzziYuZU7BY5WSC-bAXoQgWYkdsxh3rEwPY1IN8h_8YHSsy0G96mAfUj-9g-tlRjDXkNzYSbSTYYk63S5RN2LKLDaPROMI3LmTc3921xvygReltJLzubF18dMY8W8ZXs1VoEEw Download .mp4 (2.58 MB) Help with .mp4 files LAIH video clip ApicaleyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlMTg0MjJlMWFjNTVlOTkzNWI1ZmI5NGZlOGY4ZGY0MSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc1NzYwNTA0fQ.EB2L0u__X22_jVC7TfUdeOdBiJ54hHMfy-4yLe29r_pmQiuv9u1aPe0vPHZuU6Gta7yZtdjWEv4vM4DVkRUyRfUihNIJp6x7yAEW-u4KvyI_2cHb3rxHPVvJkUmR4OQZepK8wffdyCytPuZoN79dpyFd2u_Clbq5jd5vI-nHfRJjhn4zM5IMBDQvyFUV76g4F1kw3qsR4hxw5sRff8b2xHM8b4MYHfXYg4AGLO8UsxEmtzVLk0EuiZiQKhRcu3UfvK0DzSas9uhkqp1W1COQY-JQOUk3ToqQMMRQZSDR5W9Orz9-lVB4P_CTTeBgyVXSwVAD8wUaYCq3tXqOU9EdTA Download .mp4 (2.87 MB) Help with .mp4 files LAIH video clip PLAX

630 CARDIAC AMYLOIDOSIS: THE IMPORTANCE OF THE RIGHT DIAGNOSTIC TOOLS

Abstract Introduction Amyloidosis (a.) consists of the build-up of misfolded proteins in the whole body leading to life threatening organ disfunction. The most common form is the AL a., that is the result of kappa or lambda monoclonal light chains deposition as amyloid fibril. Cardiac involvement in AL a. has a high mortality. Once cardiac symptoms reveal, early diagnosis is important in order of the inverse relationship between time after the onset of cardiac symptoms and survival. Case Report A 80-y/o male was admitted in our department. Four months before he had an hospitalization in whom a coronarography was performed, showing no emodinamically signifiant lesions, leading to diagnosis of acute coronary syndrome with non occlusive coronary disease. For two months, he experienced progressive dyspnea, edema of the lower limbs and bilateral pleural effusions. On arrival, he was hemodynamically stable, his laboratory results were significant for a pro-BNP of 26,568 pg/ml and high sensitivity troponin T of 359 ng/L but without movement, the electrocardiogram showed sinus rhythm with heart rate of 72 bpm, right bundle block, non specific alterations of repolarization and low voltages. The chest X-ray showed bilateral pleural effusion. A first echocardiogram was performed and showed normal left ventricular systolic function with an ejection fraction of 60%, without wall motion abnormalities, severe concentric hypertrophy, with a left ventricular posterior wall thickness of 16 mm that is over the cutoff proposed by Marume et al., a LV septal WT of 17 mm, over the cutoff of Arvidsson at al., and a granular appearance of the myocardium, seen as hyperrefractile myocardial echoes. There was a moderate-severe diastolic dysfunction (E/E’ ratio of 22). A small pericardial effusion (8 mm) and a right ventricular dilatation (30mm) were present, too. The last parameter is a poor prognostic marker of right heart failure (in our patient there was also a tricuspid insufficiency) and a median survival of four month, as Patel et al. demonstrate. All these parameters are suspicious for storage disease, in particular amyloid deposition. M spike was not shown at serum and urine electrophoresis, and no paraproteins were found in immunofixation. However, increased kappa and lambda free light chains (248 mg/L and 31 mg/L respectively) with an increased serum and urinary kappa/lambda ratio (8.00 and 105.19) were found. Thus, a fine needle aspiration was performed, showing a bone marrow localization of Multiple myeloma (MM). A bone marrow biopsy was done but the result was still unknown at the time of discharge. A negative scintigraphy was performed. The patient was discharged from our department with a diagnosis of chronic heart failure and ongoing investigation about the link between MM and CA. One month later we have seen the result of the bone marrow biopsy that was negative for Congo red staining. During the same month the patient died, so there was no possibility to practice a cardiac biopsy. Discussion The purpose of this abstract is to emphasize the importance of fast diagnosis and cardiac biopsy in a characteristic case of clinical and echocardiogram suspicious of CA and a negative scintigraphy. Therefore the cardiac biopsy is preferable to extracardiac biopsy, as fat pad or bone marrow ones, because the cardiac one is more specific and sensitive. The heart of the matter is that it is not possible for all the departments to carry out this procedure in short-term, as in our case, and a non rapid diagnosis is linked with arrhythmic sudden cardiac death but also a rapidly worsening heart failure, as in our patient.

1935. Cardiac Tamponade Following COVID-19 Vaccination

Abstract Background While numerous, most described cases of myocarditis and pericarditis following COVID-19 vaccination are mild and self-limited. We present two cases of life-threatening cardiac tamponade following COVID-19 vaccination. Methods Two cases of cardiac tamponade in temporal association with COVID-19 vaccination were reviewed Results Case 1 : 75-year-old male with rheumatoid arthritis admitted with chest pressure and hypotension 2 days after his 1st dose of Pfizer-BioNTech COVID-19 vaccine. Pericardiocentesis removed 275 ml of exudative effusion with 14,140 nucleated cells/ml. Fluid bacterial and fungal cultures were negative; cytology was inconsistent with malignancy. He had no Epstein-Barr virus (EBV) or cytomegalovirus (CMV) viremia. Symptoms resolved on prednisone and colchicine. A week later, he had an uneventful second COVID-19 vaccine. He went on to have 3 recurrences of pericarditis starting two months after his first. One was within 48 hours of his COVID-19 booster. He is on long term prednisone. Case 2: 66-year-old male with non-Hodgkin’s lymphoma in remission. He developed chest pain a day after his 2nd dose of Pfizer-BioNTech COVID-19 vaccine. Admitted 4 days later with pericardial effusion and managed medically. Readmitted a week later with fever and chest pain. Echocardiogram now showed cardiac tamponade. Pericardiocentesis removed 400 ml of exudative fluid with 1,191 nucleated cells/mL. Cultures for bacteria, fungi, and mycobacteria were negative. Cytology didn't show malignancy. Serologies for CMV, EBV and parvovirus represented past infection. He was discharged with a pericardial drain, colchicine, and NSAIDs. He was later readmitted with fevers. Echocardiogram only showed small pericardial effusion, which did not require drainage. Figure 1Circumferential pericardial effusion seen on trans-thoracic echocardiography from patient in case 1. Conclusion Given the proximity to COVID-19 vaccination and lack of alternative explanations, we believe that tamponade was a direct result of post-vaccine inflammatory pericarditis. Neither patient had a prior history of pericardial effusion. Both tested negative for SARS-CoV-2 by nasopharyngeal swab excluding active infection. Healthcare providers should consider the possibility of pericardial effusion and tamponade in patients with chest pain, shortness of breath, or hypotension following COVID-19 vaccination. Disclosures All Authors: No reported disclosures.

Prognostic impact of small pericardial effusion in acute heart failure.

The relationship between small pericardial effusion (SPE) and outcomes has not been well studied in patients with heart failure. Therefore, we aimed to investigate the prevalence and importance of SPE in acute heart failure (AHF). A total of 398 hospitalized patients with AHF were retrospectively reviewed. Patients' baseline demographic, clinical, echocardiographic, and laboratory characteristics were noted. SPE was defined as the presence of a pericardial effusion <10mm. The primary outcome was one-year mortality. SPE was noted in 54 (13.6%) of the patients. Mortality at one year was greater for patients with a small effusion compared with those without SPE (44.4vs. 11.4%, respectively; p<0.001), and the one-year mortality rate for the whole group was 15.8%. Age (HR=1.12, 95% CI 1.054-1.854, p=0.024), N-terminal pro-B-type natriureticpeptide>4800 pg/ml (HR=1.628, 95% CI 01.102-4.805, p=0.001), left ventricular ejection fraction <30% (HR=1.878, 95% CI 1.154-4.524, p=0.001), and presence of SPE (HR=1.567, 95% CI 1.122-2.991, p=0.005) were independent predictors of one-year mortality on multivariate analysis. The presence of SPE on admission was an independent predictor of one-year mortality in AHF.

Abstract 9616: A Cardiac Mass in the Postpartum: A Diagnostic and Therapeutic Dilemma

Introduction: Precise diagnosis of a cardiac mass has crucial prognostic and therapeutic implications. Case Presentation: A 23-year-old woman presented to an outside hospital 6 days after delivery with headaches, chest pain and very high BP. A CT angiogram found no pulmonary emboli but identified a mass in the right atrium. Surgical removal was attempted but had to be aborted because of inability to get clear margins. Frozen section showed atypical spindle cells, suggestive of sarcoma. Patient was transferred to our hospital for further management. TTE (Figure) revealed a large solid mass almost entirely filling the right atrium and a small pericardial effusion. CMR showed a 7.2 cm hypervascular mass in the right atrium with possible invasion of the superior vena cava, suggestive of angiosarcoma. Additional tissue sections showed vascular spaces lined by benign endothelial cells positive for the endothelial markers ERG, CD31 and CD34 and infiltrating the underlying myocardium; proliferation rate was &lt;1%. Based on these findings a diagnosis of primary cardiac hemangioma was made. Subsequent PET CT showed mildly FDG-avid cardiac mass and no metastases. Discussion: Cardiac masses are a diagnostic challenge. Identification hinges on clinical history, location and multimodality imaging but histopathology and immunohistochemistry remain the gold standard for a definitive diagnosis. Primary cardiac tumors are rare, found only in &lt;0.05% of autopsies; 80% are benign and 20% malignant. Hemangiomas are extremely rare, representing &lt;3% of primary cardiac tumors. They are often misdiagnosed as other neoplasms, as was the case in our patient, possibly leading to unnecessary invasive procedures. Although benign, hemangiomas can infiltrate surrounding structures and cause serious complications, such as syncope, emboli, arrhythmias, heart block and stroke. Complete surgical excision remains the treatment of choice and, if successful, confers a positive prognosis.

Abstract 14332: Syncope, Storm, and Shock: Fulminant Myocarditis

A 46-year-old female with prediabetes and recent hysterectomy three weeks prior presented to the hospital for syncope. Patient reported no chest pain or dyspnea but complained of intermittent palpitations. The patient developed runs of non-sustained ventricular tachycardia which quickly escalated into incessant ventricular tachycardia (VT). Unresponsive to maximal medical therapy, the patient was cardioverted, intubated and sedated. Electrocardiogram was obtained which showed ST segment elevation in V1 and V2 without reciprocal changes. Bedside point-of-care ultrasound was negative for wall motion abnormalities. Laboratory results were significant for normal electrolytes, elevated troponins peaking at 7.14 ng/mL the following morning, and lactic acid of 3.2 mmol/L. Patient was initiated on vasopressor and ionotropic support for suspected shock. Left heart catheterization was negative for obstructive coronary artery disease. Right heart catheterization revealed mild pulmonary hypertension and biventricular failure. Formal echocardiogram revealed mid-range ejection fraction with a small pericardial effusion. The patient’s clinical status was deteriorating and revealed multiorgan failure. In conjunction with advanced heart failure and mechanical circulatory support teams, veno-arterial extracorporeal membrane oxygenation was initiated with subsequent implantation of intra-aortic balloon pump. High-dose steroids were given while awaiting transfer to a quaternary center. The patient is currently being evaluated for endomyocardial biopsy and evaluation of left ventricular assist device or heart transplantation due to fulminant myocarditis (FM). FM requires early recognition, intensive support, and further investigation for optimal management.

Abstract 15382: Geriatric HFpEF: When It Isn’t Hypertensive Heart Disease

Introduction: Transthyretin amyloid cardiomyopathy (ATTR) is thought to be a rare cause of HF, but recent studies showed this is the cause of 30% of HFpEF patients older than 75. With new treatments for amyloidosis, timely diagnosis has become critical. Case: A 78-female with HFpEF, HTN, and diabetes followed for progressive functional decline and hospitalizations for HFpEF exacerbations. EKG at baseline showed LBBB with normal QRS voltages. Serial echocardiogram (echo) showed an ejection fraction (EF) of 60-70%, mild LVH, and moderate TR with RVSP &gt;50 mmHg. Latest echo showed progressive LA enlargement, MR, a new small pericardial effusion, and EF 50%. Regadenoson nuclear scan showed normal perfusion with preserved LVEF. Despite adequate control of her HTN, dyspnea continued to worsen. Because of this, the diagnosis of Cardiac amyloidosis was considered. Further review revealed a history of Carpal Tunnel Syndrome (CTS) and speckled pattern within the ventricular wall on echo. A technetium pyrophosphate scintigraphy ( 99m Tc-PYP) confirmed ATTR with grade three uptake, AL amyloid was ruled out with normal SPEP/UPEP, and she was started on Tafamidis. Discussion: Cardiac amyloidosis should be considered in HFpEF patients with functional decline despite medical optimization. It can mimic LVH caused by HTN on echo and easily dismissed in patients with traditional risk factors, but presence of CTS or lumbar spinal stenosis can be supportive. Traditionally ATTR is associated with low-voltage EKG, however this patient presented with normal QRS voltages for years, making the diagnosis more elusive. Conclusion: Advances in noninvasive imaging and treatments allow for early diagnosis of cardiac amyloidosis, reducing morbidity and mortality. Diagnosis is often delayed or missed, as features could be subtle and mimic other more common cardiac disease. Screening&amp;nbsp; 99m Tc-PYP for elderly patients with HFpEF could translate to improved outcomes

Abstract 10781: An Unusual Case of Transient Inflammatory Constrictive Pericarditis: IgG4 Disease

Case Presentation: A 54-year-old male with a past medical history of hypertension presented with chest tightness, shortness of breath, fatigue, and ankle edema. His vital signs were within normal limits but physical exam was significant for jugular venous distension and bilateral peripheral edema. Laboratory studies were unremarkable except for elevated inflammatory markers (C-reactive protein [23.6 mg/dl] and erythrocyte sedimentation rate [34 mm/hour]). Interferon assay, Influenza A/B antigens and anti-nuclear antibody were negative. The patient was diagnosed with constrictive pericarditis (CP). Although the patient was treated appropriately for pericarditis with a steroid taper, colchicine and ibuprofen, his symptoms recurred. Therefore, he underwent a radical pericardiectomy which resulted in a marked clinical improvement. The final pericardial pathology revealed fibrosis and plasma cell infiltrates with &gt;30% of cells positive for IgG4. An echocardiogram revealed a small pericardial effusion with septal bounce, annulus reversus, and a plethoric inferior vena cava consistent with a diagnosis of CP. Cardiac magnetic resonance imaging showed a small circumferential pericardial effusion and respirophasic septal flattening during inspiration with marked pericardial delayed enhancement (DHE). Discussion: CP is commonly caused by viral or idiopathic etiologies, with infection (tuberculosis) being more prominent in developing countries. IgG4 disease is an uncommon cause of CP with only a few cases of IgG4-related CP have been reported. Pathological findings on histology include IgG4-positive lymphoplasmacytic cells and fibrosis. The disease is characterized by steroid-responsive condition but pericardiectomy is pursued with a suboptimal response. Cardiovascular manifestations of IgG4 disease are under explored and our case illustrates the importance of recognizing and treating the pericardial complications of IgG4 disease.

Abstract 15745: Effusive Constrictive Pericarditis After Covid-19 Vaccination

Case Report: A 42-year-old male with no significant past medical history presented to the emergency department (ED) after a three-week history of myalgias, non-productive cough, and progressively worsening dyspnea accompanied by a two-week history of right-sided chest pain that all started four days after receiving his Pfizer COVID-19 booster vaccine. Chest pain was described as constant, non-radiating, and aggravated by positional changes. On ED arrival, the patient was febrile to 102.9°F and tachycardic with initial labs significant for leukocytosis of 13.6 Thou/uL, C-reactive protein at 17.18 mg/dL, troponins negative x2, and a negative COVID-19 NAAT testing. EKG revealed diffuse T wave inversions and chest x-ray was noncontributory. Transthoracic echocardiogram (TTE) obtained showed a small fibrinous circumferential pericardial effusion with no evidence of cardiac tamponade; however, there was an interventricular septal bounce suggestive of effusive-constrictive pericarditis. This diastolic septal bounce was also seen on cardiac magnetic resonance imaging, along with a pericardial enhancement measuring up to 0.2 cm in thickness. With a negative infectious and autoimmune workup, along with low clinical suspicion for tuberculosis or malignancy, the leading differential was the temporal relationship between receiving the Pfizer COVID-19 mRNA booster vaccine and the development of effusive-constrictive pericarditis (ECP). The patient was started on Colchicine 0.6 mg twice daily, Ibuprofen 400 mg three times daily, and subsequently discharged after symptomatic improvement and being afebrile for 72 hours with plans for close cardiology follow-up. Discussion: ECP is a rare syndrome characterized by a concurrent decrease in pericardial compliance with pericardial effusion and is seen in 4.5% to 6.9% of patients who present with pericardial effusions. To date, less than five other case reports internationally have delineated a relationship between COVID-19 mRNA vaccines and the development of ECP, making recognition of this etiology challenging. In patients who have a mixed hemodynamic picture with subacute features of both cardiac tamponade and constrictive pericarditis, clinicians should have a high index of suspicion for ECP.

Abstract 12990: A Strange Case of Pericarditis: Pericarditis With Pneumopericardium Caused by a Misplaced G Tube

Introduction: Most cases of pericarditis are idiopathic, consideration of other differentials remains essential. We present a 53 year-old-male who presented with pericarditis with pneumopericardium caused by a misplaced gastrostomy tube (G-tube). Case Description: A 53 year-old-male with autosomal dominant polycystic kidney disease on hemodialysis, encapsulating peritoneal sclerosis with percutaneous G-Tube for decompression, presented to the hospital with an acute sharp left sided chest pain. Vitals were unremarkable except for tachycardia. Physical exam revealed abdominal distension with tenderness elicited in the right upper quadrant and epigastric regions, with a G-tube in place with no erythema or tenderness along skin. A rub or pulsus paradoxus was not appreciated. EKG showed sinus tachycardia with diffuse ST elevations suggestive of acute pericarditis. Blood work including troponins were unremarkable except for BUN of 104 mg/dL. In suspicion of uremia, daily hemodialysis was initiated with prednisone. Patient did not respond to therapy despite improvement in uremia. CT imaging revealed a pneumopericardium [Tan arrow - Figure 1] which was in communication with the G-Tube, dislodged from its initial position [White arrow - Figure 1]. The G-Tube was later clamped and an echocardiogram revealed a small posterior pericardial effusion without tamponade. Patient later underwent surgical removal of the G-Tube followed by endoscopic suture closure of the fistula with symptom resolution. Conclusion: Although idiopathic pericarditis encompasses most of the cases, concerns should be raised for those patients that have atypical presentations, comorbidities and who do not respond to initial therapy.

MALIGNANCY MASQUERADING AS STEROID RESISTANT HYPEREOSINOPHILIA SYNDROME

<h3>Introduction</h3> Hypereosinophilia syndrome (HES) is defined as 1500 eosinophils/mL or above with evidence of end-organ damage due to the eosinophils at least 4 weeks apart. <h3>Case Description</h3> A 3-year-old male was admitted for newly found anterior mediastinal mass and left pleural effusion. About 6 weeks prior to admission, he was seen in his primary care office for difficulty breathing. Despite the appropriate treatment for his symptoms, the patient continued to have significant respiratory symptoms and a chest x-ray showed a large left pleural effusion. He was immediately transferred to a tertiary care center and a CT chest showed large left pleural effusion, possible abscess, small pericardial effusion, and concern for an anterior mediastinal mass due to mediastinal shift. He underwent a thoracentesis, which showed eosinophilia within the pleural fluid. While his peripheral eosinophils had fluctuated at the beginning of his hospitalization, the patient's absolute eosinophil count suddenly increased from 600 to 25,048 and remained elevated above 20,000. He developed recurrent eosinophilic pericardial effusions requiring multiple pericardiocentesis. Despite high dose steroids and inpatient use of mepolizumab, his hypereosinophilia persisted. After two inconclusive fine-needle aspirations of his mediastinal mass, the patient's family agreed to a thoracotomy with removal of the mediastinal mass. Pathology eventually revealed myeloid sarcoma, a variant of acute myeloid leukemia. <h3>Discussion</h3> Steroid resistant HES should raise concern for underlying malignancy especially when eosinophils are above 20,000.

Medium-term outcomes of myocarditis and pericarditis following BNT162b2 vaccination among adolescents in Hong Kong

ABSTRACT In this study, we examined the clinical and electrophysiological outcomes of adolescents in Hong Kong who developed myocarditis or pericarditis following BNT162b2 vaccination for COVID-19, and followed-up for 60–180 days after their initial diagnosis. Clinical assessments included electrocardiogram (ECG) and echocardiogram at the initial admission and follow-up were compared. Treadmill testing was also performed in some cases. Between 14 June 2021 and 16 February 2022, 53 subjects were approached to participate in this follow-up study, of which 28 patients were followed up for >60 days with a median follow-up period of 100 days (range, 61–178 days) and were included in this study. On admission, 23 patients had ECG abnormalities but no high-grade atrioventricular block. Six patients had echocardiogram abnormalities, including reduced contractility, small rim pericardial effusions, and hyperechoic ventricular walls. All patients achieved complete recovery on follow-up. After discharge, 10 patients (35.7%) reported symptoms, including occasional chest pain, shortness of breath, reduced exercise tolerance, and recurrent vasovagal near-syncope. At follow-up, assessments, including ECGs, were almost all normal. Among the three patients with possible ECG abnormalities, all their echocardiograms or treadmill testings were normal. Sixteen patients (57.1%) underwent treadmill testing at a median of 117 days post-admission, which were also normal. However, at follow-up, there was a significant mean bodyweight increase of 1.81 kg (95%CI 0.47-3.1 kg, p = 0.01), possibly due to exercise restriction. In conclusion, most adolescents experiencing myocarditis and pericarditis following BNT162b2 vaccination achieved complete recovery. Some patients developed non-specific persistent symptoms, and bodyweight changes shall be monitored.

The Impact of Bedside Cardiac Point-of-Care Ultrasound on the Utilization of Cardiology Subspecialty Resources in a Pediatric Emergency Department.

This study sought to determine the impact of cardiac point-of-care ultrasound (cPOCUS) in a pediatric emergency department (ED) on cardiology subspecialty utilization for subjects with chest pain or syncope. Diagnostic yield of cPOCUS and transthoracic echocardiograms (TTEs) for these subjects was also examined. A retrospective chart review of subjects presenting to a tertiary pediatric ED with chest pain or syncope 1 year before (2015, pre-cPOCUS group) and 1 year after (2017, cPOCUS group) introduction of cPOCUS was conducted. Subjects aged 2 to 18 years evaluated for these symptoms were included. Those with known heart defects, prior abnormal TTE, or asthma exacerbation at presentation were excluded. In both groups, cardiology subspecialty utilization was assessed by determining whether cardiology referrals, cardiology consultations, or follow-up TTEs were completed. Results of TTEs were reviewed and classified as incidental (no follow-up needed), minor (follow-up needed, but intervention unlikely), moderate (nonurgent intervention needed), and severe (hospitalization/urgent intervention needed). Cardiac point-of-care ultrasound results were compared with any follow-up TTEs. Data were analyzed using χ 2 or Student t test as appropriate. A total of 1230 subjects were analyzed: 595 pre-cPOCUS and 635 cPOCUS group. There was no significant difference in TTEs (42 vs 46), cardiology consultations (36 vs 37), or cardiology referrals (47 vs 37) between groups. Of 67 cPOCUS scans performed, 63 were normal, 3 showed small pericardial effusion, and 2 demonstrated left ventricular dysfunction. Of 88 TTEs in both groups (0.7% subjects), 76 were normal, 5 had incidental, 6 had minor, and 1 had a severe finding present on cPOCUS (0.08% subjects; 95% confidence interval, 0%-0.45%). The introduction of cPOCUS did not increase cardiology subspecialty utilization in subjects presenting to the pediatric ED with chest pain or syncope. Cardiac point-of-care ultrasound may be useful in evaluating global biventricular systolic function and effusion in this population.

Post COVID-19 cardiac magnetic resonance findings among inpatients vs outpatients

Abstract Background Myocardial injury and myopericarditis constitute an important complication after viral infection. The prevalence of myocardial injury among patients that survived COVID – 19 infections and its causes are still not clear. The purpose of this study is to estimate whether there is a difference in the prevalence of cardiac magnetic findings between patients treated in a hospital vs patients treated at an outpatient clinic. Methods We evaluated 360 cardiac magnetic resonance examinations, performed from 1st of June 2020 until the 31st of August, 2021. Out of them, 141 patients (39%) underwent cardiac magnetic resonance due to persistent symptoms after a SARS-CoV-2 infection. A conventional CMR protocol was performed to rule out myocarditis. Revised 2018 Lake Louise Criteria were used to diagnose myocarditis. All scans were performed by Phillips Medical Systems Ingenia 1.5T. T1 native values were estimated elevated when mapping values measured above 1030ms, T2 mapping values were estimated elevated when greater than 55 ms. Mid wall or subepicardial late gadolinium enhancement, pericardial effusions and extracardiac findings were evaluated. Chi-square test was used. Results Out of 141 patients, 78 patients (55%) had at least one cardiac magnetic resonance finding: either increased T1 (22%), T2 mapping (7%), T2 STIR (1.4%), left gadolinium enhancement (30%), small pericardial effusion (26%) or lung parenchymal changes (12%) after COVID-19. Twenty out of 141 patients (14%) fulfilled the criteria for myocarditis. Out of these 20 patients, 14 patients (70%) received treatment at an outpatient clinic, while 6 patients (30%) were treated from COVID-19 in a hospital (p&amp;lt;0.053). The most prevalent symptoms were effort intolerance and palpitations (50% and 26% respectively). There was no statistical difference in myocarditis prevalence, between hospitalized patients treated with or without corticosteroids (p=0.65), as well as between patients treated with hemodiafiltration (Oxiris filter) and patients without hemodiafiltration (p=0.95). Also, there was no statistical difference between T1 mapping among the inpatients and outpatients (p=0.58), as well as the severity of the clinical picture (p=0.72). There was no statistical difference between the in- and outpatient groups according to age (p=0.46). None of these patients had signs of fulminant myocarditis. Conclusion The prevalence of myopericardial and/or lung involvement after SARS-CoV-2 infection is present in every other cardiac magnetic resonance examination performed for persistent symptoms after a survived COVID-19. Myocarditis after SARS-CoV-2 infection develops regardless of the severity of the symptoms or the treatment method. We can conclude that we have to look for the reasons for myocarditis, beyond the clinical picture and the treatment strategies. Funding Acknowledgement Type of funding sources: None.

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