Case Presentation:

55-year-old Hispanic female with no significant past medical history who was in her usual state of health presented with complaints of multiple syncopal episodes that were preceded by nausea and vomiting for three days.  While awaiting evaluation, the patient had a syncopal episode and was found to be hemodynamically unstable with hypotension and tachycardia.  Emergent cardiac ultrasound revealed a 3 cm circumferential pericardial effusion, right ventricular early diastolic collapse and plethoric non-collapsible inferior vena cava consistent with increased intra-cardiac pressures.  The patient had a pericardial window placed after an unsuccessful emergent pericardiocentesis.  Biopsy of the pericardial tissue revealed concern for metastatic adenocarcinoma of likely gastrointestinal or pancreatobiliary origin.  Further imaging with computed tomography of chest, abdomen, and pelvis and nuclear medicine bone scan showed bilateral pleural effusions without evidence of primary malignancy.  Esophagogastroduodenoscopy revealed a diffuse hard stomach, irregular thickened folds and difficulty in distending the stomach most concerning for linitis plastica.  Gastric biopsies revealed poorly differentiated signet ring cell carcinoma.  After extensive discussions regarding the prognosis and possible treatment options, she chose to pursue palliative options.

Discussion:

Cardiac tamponade is an important consideration when hospitalists evaluate patients with hemodynamic instability since prompt intervention with pericardiocentesis or pericardial window placement can be life-prolonging.  This patient case illustrates the advantage to utilizing basic ultrasound skills for prompt evaluation.  The incidence of malignancy as the underlying etiology of cardiac tamponade is anywhere between 15 to 30% however cardiac tamponade as the initial presentation of cancer is extremely rare.  Lung and breast cancer are the most common cancers that metastasize to the pericardium along with Hodgkin’s disease, leukemia and melanoma which can all result in pericardial effusions.  Not only is the diagnosis of primary gastric signet ring cell carcinoma uncommon but metastasis to the pericardium resulting in cardiac tamponade as the initial presentation is extremely rare with only a few case reports describing a similar presentation.

Conclusions:

Hospitalists will often be the first responders to patients who develop hemodynamic instability.  This case highlights the increasing role of basic ultrasound skills which quickly diagnosed cardiac tamponade and led to prompt intervention.  Underlying malignancy is a common cause of cardiac tamponade so pericardial fluid should be evaluated for cytology.  Cardiac tamponade as the initial presentation of primary gastric signet ring cell carcinoma associated with linitis plastica is very rare.