Case Presentation:
A 50–year–old African American woman with history of tobacco use (35 pack–years) and hypersensitivity pneumonitis presented with shortness of breath and chest pain for the past 2 weeks. Chest pain is pressure in nature, non–radiating, mid chest better with leaning forward. This was associated with orthopnea, dry cough and loss of appetite for 2 weeks. She has no known TB exposure or recent travel and she is up to date with cancer screening. On exam, she was afebrile, HR 110 and SBP 90 mmHg, positive pulsus paradoxus, JVD of 12 cm along with distant heart sounds. Bedside echocardiogram reveals a large pericardial effusion, swinging heart, mitral valve inflow variation of almost 50%, RA collapse, early LA collapse and plethoric IVC that does not collapse with inspiration. She underwent a pericardiocentesis and 500 ml of bloody fluid was retrieved. TB quantiferon test was negative. Fluid analysis with cytology reveals adenocarcinoma. CT chest shows mediastinal and bilateral hilar lymphadenopathy and irregular right upper lobe nodule. These findings were not seen on recent images when following up with pulmonary 4 months ago. PET was positive for a 1.5 × 1.2 cm nodule in the right upper lobe, bilateral multiple lung nodules, pericardial nodules and left low neck lymph node involvement. She underwent bronchoscopy with biopsy, which revealed adenocarcinoma. She continued to have recurrent pericardial effusion with tamponade and underwent a subxiphoid pericardial window. CT brain was negative for metastasis. She tolerated four cycles of carboplatin and pemetrexed. Her post–treatment PET reveals complete remission in lung and mediastinal lesions.
Discussion:
About 10% of patients with advanced malignancies including lung have pericardial involvement. However, cardiac tamponade is an unusual initial presentation of underlying lung adenocarcinoma with only few cases reported in the literature. Management is tailored through stabilizing the patient hemodynamically. Hemopericardium is considered a red flag for malignancy. Further malignancy workup and whole body imaging is necessary based on patient’s age and risk factors for certain malignancies. Subxiphoid pericardial window is usually recommended in patients with a long life expectancy. Current literature suggests that the presence or recurrence of cardiac tamponade is associated with worse prognosis.
Conclusions:
Hospitalists have to be vigilant about recognizing Beck’s triad (decreased systolic pressure, jugular venous distension, and distant, muffled heart sounds) in patient presented with shortness of breath. This is caused by cardiac tamponade (due to trauma, post heart surgery, uremia or cancer). Lung cancer usually presents with shortness of breath and chronic cough. It has been reported that lung cancer can metastasize to pericardium and cause pericardial effusion. However, it is uncommon that cardiac tamponade will be the initial presentation for a patient with underlying undiagnosed lung cancer.