A 67 year old male with a history of hypertension presented to the hospital with sudden onset of worsening, positional chest pain and shortness of breath. Pt was worked up for acute coronary syndrome and noted to have a pericardial effusion. It was thought to be due to viral infection as the patient had a recent upper respiratory tract infection. Patient was discharged on symptomatic treatment. The patient shortly thereafter, had a similar presentation and was re-admitted. This time again the patient was noted to have a pericardial effusion on Echocardiogram but a larger amount. He underwent drainage of the pericardial fluid revealing about 800cc of hemorrhagic fluid which was sent for investigation including fungal, viral, acid fast bacteria and cytology. All results were negative with the exception of cultures which showed growth of peptostreptococci. This was thought to be insignificant but still he was treated with antibiotics because infection was considered a possible etiology. At this time, a rheumatologic laboratory work up was also initiated, including antinuclear antibody, lupus anticoagulant, connective tissue cascade, and cytoplasmic- antineutrophilic cytoplasmic antibodies, which revealed negative results. By this time, the patient already had five documented episodes of pericarditis but still, a clear cut etiology could not be determined. On reviewing the work up done so far, the patient was noted to have normocytic, normochromic anemia with an increased serum albumin to total protein ratio. This prompted the test for serum plasma electrophoresis which revealed a kappa free light chain with monoclonal peak. This finding led to a bone marrow biopsy which showed 60% plasma cell dyscrasia consistent with the diagnosis of multiple myeloma. After the patient was started on chemotherapy for multiple myeloma, the pericardial effusion resolved.
Multiple myeloma is a plasma cell disorder in which malignant cell accumulate in the bone marrow and interfere with normal functioning. Also, production of paraprotein interferes with kidney functions. Pericardial effusion had been a known complication of multiple myeloma and there have been case reports regarding malignant pericardial effusion causing tamponade. Pericardial involvement is extremely rare. About 1% and may occur any time during the course of disease. Important clues in the basic testing may lead to early diagnosis and initiation of treatment at an early stage.
Anemia and reversed A/G ratio should be carefully investigated and this Important clue for diagnosis of multiple myeloma. Diagnosis of malignant pericardial effusion is of prognostic value as it is associated with poor survival .