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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 61-63

Cardiac tamponade is a rare presentation of unknown primary malignancy


Department of Internal Medicine, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission29-May-2021
Date of Acceptance30-Aug-2021
Date of Web Publication28-Feb-2022

Correspondence Address:
Manjunath Totaganti
Department of Internal Medicine, AIIMS, Rishikesh, Uttarakhand.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCDM.JCDM_10_21

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  Abstract 

Pericardial effusion is one of the common medical conditions in clinical practice. It can present as ranging from asymptomatic to shock as in cardiac tamponade. Underlying etiology is diverse, including infections, metabolic, autoimmune, and neoplastic. Cardiac tamponade is a medical emergency, making it crucial for identification. It is treated with immediate pericardiocentesis for symptomatic management, followed by identifying the underlying cause. Here we present an interesting case, presented as cardiac tamponade with underlying malignancy.

Keywords: Cardiac tamponade, malignancy, pericardiocentesis, shock


How to cite this article:
Totaganti M, Devi YM, Chakravarthy P, Sharma D. Cardiac tamponade is a rare presentation of unknown primary malignancy. J Cardio Diabetes Metab Disord 2021;1:61-3

How to cite this URL:
Totaganti M, Devi YM, Chakravarthy P, Sharma D. Cardiac tamponade is a rare presentation of unknown primary malignancy. J Cardio Diabetes Metab Disord [serial online] 2021 [cited 2022 Aug 10];1:61-3. Available from: http://www.cardiodiabetic.org/text.asp?2021/1/2/61/338606




  Case Presentation Top


A 50-year-old man without any addictions, without any comorbidities, presented with complaints of sudden-onset shortness of breath of 2 days’ duration without any history of orthopnea, paroxysmal nocturnal dyspnea, cough, and fever.

On general physical examination, he was restless and was in respiratory distress using the accessory muscles of respiration. His pulse was 120/min, respiratory rate was 24/min, and blood pressure was 90/60 mm Hg. He had pallor, and his peripheral pulses were feeble along with distended neck veins. Systemic examination revealed absent apical impulse, with muffled heart sounds; the findings of the rest of the examination were normal. He was clinically diagnosed with pericardial effusion.

Electrocardiogram (ECG) was done and suggested sinus tachycardia with low-voltage complexes [Figure 1]. The chest X-ray indicated the money bag appearance of cardiac shadow and bilateral pleural effusion [Figure 2].
Figure 1: Showing low-voltage complex

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Figure 2: Showing features of tamponade

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Immediate 2D ECHO was done, showed [Figure 3] large pericardial effusion with early right ventricle diastolic collapse suggesting the tamponade physiology. He was started on intravenous fluids till he was shifted to the cath lab. Emergency therapeutic pericardiocentesis was done.
Figure 3: Chest X-ray showing b/l effusion with tamponade

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Throughout 72 h, approximately 2 L of hemorrhagic fluid was removed. Considering the nature of the illness, the below differential diagnosis was kept.

  1. Tubercular pericarditis


  2. Malignant pericardial effusion


The fluid was sent for evaluation, including cytology and tuberculosis. The cartridge based nucleic acid amplification test of the fluid came to be negative, and the malignant cytology cells were positive, suspicious of adenocarcinoma. His initial contrast enhanced computed tomography abdomen showed multiple enhancing lesions in the liver [Figure 4], along with multiple pleural nodules.
Figure 4: Contrast enhanced computed tomography abdomen showing multiple enhancing lesions

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He was discharged after stabilization and was planned for the pleural biopsy on an outpatient basis. The patient was lost to follow up during the second wave of COVID-19.


  Discussion Top


Pericardial effusion is a fluid collection in the pericardial space usually associated with various local or systemic diseases. The clinical presentation is varied based on the celerity and volume of fluid in the pericardial space.[1] When the amount of fluid is ample to cause the compression on the heart, it can lead to obstructive shock named cardiac tamponade, which is a medical emergency.

The clinical findings of tamponade are classically described by the becks triad, including hypotension, distended jugular veins, and muffled heart sounds. The symptoms may be nonspecific and include breathlessness, fever, chills, chest pain, cough, edema, orthopnea, and paroxysmal nocturnal dyspnea.[2] These findings will depend on the rate of accumulation. As in iatrogenic wounds, the trauma of the fluid will accumulate rapidly, and small amounts can lead to tamponade physiology. Diseases in which slow accumulation of fluid occurs, leads to sufficient time to accommodate and symptoms appear once the fluid is large enough, over weeks.[3] Signs include increased jugular venous pressure, pulses paradoxus, diminished heart sounds, low blood pressure, and pericardial rub.

ECG shows low-voltage complexes and nonspecific ST-segment changes. The diagnosis is clinched by echocardiography, demonstrating multiple signs, including the following:[4]

  1. Large effusion with swinging heart


  2. Diastolic collapse of the right atrium (RA) and right ventricle (RV)


  3. Duration of RA inversion by the RA inversion time index (duration of inversion/cardiac cycle length); for values >0.34


  4. Inferior vena cava (IVC) plethora (dilatation >20 mm and <50% reduction in the diameter of IVC with respiratory phases


As we know, it can be caused by multiple etiologies. Cancer-related tamponade is one of the most common causes. Sagristà-Sauledaet al. documented that approximately 13% of these cases were related to cancer.[5] However, the tamponade as initial presentation is uncommon in an undiagnosed case of malignancy, supported by the availability of few cases, and is a poor indicator of survival.[6]

The cornerstone of the management is drainage of the fluid and management of underlying etiologies. Intravenous fluids also play a major role in managing tamponade as they increase the preload to counter the extrinsic pressure on the right ventricle. Fluid can be drained via varied approaches, including ranging from simple drainage to thoracic surgery. The approach can be decided based on the stage of cancer and the patient’s prognosis.[7] Palliative care would be the primary aim in the management of malignant pericardial effusion. Long-term therapy extended drainage, sclerosant local therapy, and chemoradiotherapy either locally/systemic route.


  Learning Points/Take Home Messages Top


  • • Pericardial effusion is one of the common presentations in malignancies.


  • • Tamponade as an initial presentation in underlying malignancy is rare.


  • • Early recognition and timely intervention is the key for the management of a case of cardiac tamponade.


  • • Malignant effusion is a poor prognostic marker.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shabetai R Pericardial effusion: Haemodynamic spectrum. Heart 2004;90:255-6.  Back to cited text no. 1
    
2.
Roy CL, Minor MA, Brookhart MA, Choudhry NK Does this patient with a pericardial effusion have cardiac tamponade? JAMA2007;297:1810-8.  Back to cited text no. 2
    
3.
Spodick DH Acute cardiac tamponade. N Engl J Med 2003;349:684-90.  Back to cited text no. 3
    
4.
Fowler NO Cardiac tamponade: A clinical or an echocardiographic diagnosis? Circulation 1993;87:1738-41.  Back to cited text no. 4
    
5.
Sagristà-Sauleda J, Mercé J, Permanyer-Miralda G, Soler-Soler J Clinical clues to the causes of large pericardial effusions. Am J Med 2000;109:95-101.  Back to cited text no. 5
    
6.
Ballardini P, Margutti G, Zangirolami A, Tampieri M, Incasa E, Gamberini S, et al. Cardiac tamponade as unusual presentation of underlying unrecognized cancer. Am J Emerg Med 2007;25:737.e5-6.  Back to cited text no. 6
    
7.
Imazio M, Brucato A, Mayosi BM, Derosa FG, Lestuzzi C, Macor A, et al. Medical therapy of pericardial diseases: Part I: Idiopathic and infectious pericarditis. J Cardiovasc Med (Hagerstown) 2010;11:712-22.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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