Case Presentation: An 83 year old male presented with new onset shortness of breath, generalized weakness and fatigue for 4 days. Physical examination revealed mild hypotension and diminished heart sounds. Chest radiology showed enlargement of cardiac silhouette. A transthoracic echocardiogram was significant for large pericardial effusion suggestive of an early tamponade. The patient underwent a procedure for pericardial window and 1150 ml of hemorrhagic pericardial fluid was drained . Pericardial fluid cytology revealed aggressive, stage IV, Non-Hodgkin B cell lymphoma with high Ki-67 proliferation index of 80%. The cytological analysis demonstrated features intermediate between Burkitt’s and Diffuse Large B-cell Lymphoma with increased staining by BCL-2 as well as C-MYC, thus conferring worse prognosis than most large B cell lymphomas. Eventually, the patient was started on chemotherapy EPOCH-R (Etoposide, Prednisolone, Oncovin, Cyclophosphamide- Rituximab).
Discussion: Many patients with NHL come to medical attention because of the discovery of lymphadenopathy. However, systemic symptoms such as fever, night sweats or weight loss can be the first signs of disease. Cardiac involvement by malignant lymphoma is a rare condition, representing approximately 1·3% of cardiac tumors and 0·5% of extra-nodal non-Hodgkin lymphoma (NHL). An important oncologic emergency associated is the pericardial tamponade whose long term management can be challenging. Fluid analysis plays a major role if there is no extensive tumor spread for biopsy and also because NHL usually gives chylous pericardial effusion.
Conclusions: Pericardial involvement is infrequent over the course of Non Hodgkin’s lymphoma, and pericardial tamponade is rarely the initial presentation. A multidisciplinary approach is necessary for a favorable outcome. Management involves stabilizing the patient by relieving the tamponade, followed by appropriate diagnostics for the fluid and eventual systemic chemotherapy for the underlying malignancy.