Case Presentation:
A 50‐year‐old African American woman presented with a 3‐week history of cough and worsening shortness of breath. Her past medical history included hypertension, depression, and smoking. The patient also claimed she had been admitted to the hospital 2 years prior for presumed pneumonia and COPD that eventually required short‐term mechanical respiratory ventilation. The patient had been well since then until again presenting with low‐grade fever of 100.4F, pulse 100, RR 34, BP 86/60 and bilateral diffuse wheezing and crackles on lung auscultation. White count was 8.4 and ECG showed sinus tachycardia. A Chest x‐ray noted a 2 cm spiculated left upper lobe mass, bilateral lower lobe infiltrates, and moderate right pleural effusion. The patient was treated for presumed COPD and pneumonia/sepsis with antibiotics, steroids, and bronchodilators. Blood pressure and respiratory status improved significantly by withholding her outpatient regimen of Atenolol. A right‐sided thoracentesis resulted in a transudative pleural fluid that was negative for malignant cells. A CT scan of the chest confirmed the presence of the left upper lobe mass and right and mediastinal hilar adenopathy. CT scan of the abdomen and pelvis was negative for metas‐tases. The patient responded quickly to the above treatment, and a subsequent bronchoscopy was performed in which the cytologic washing proved positive for malignant cells, favoring adenocarcinoma. The patient was evaluated by oncology with subsequent plan to continue work up and staging for lung cancer as an outpatient. The day before discharge was planned, the patient complained of twenty minutes of pleuritic chest pain and shortness of breath. Blood pressure and pulse were withing normal range. However, a STAT ECG indicated the presence of electrical alternans. An emergent 2D echo was performed and showed findings consistent with pre‐clinical tamponade. The patient underwent successful pericardial window and drainage. Pericardial fluid was also positive for adenocarcinoma.
Discussion:
Metastases to the heart and pericardium are much more common than primary cardiac tumors and are generally associated with a poor prognosis. Malignant pericardial effusion is often associated with cancers of the lung and breast, melanoma, and lymphoma. Patients frequently complain of shortness of breath, cough, and pleuritic chest pain. These symptoms, however, can often be misinterpreted to those caused by associated lung disease such as pneumonia and/or pleural effusion. Tamponade can develop very rapidly in patients with pericardial effusion. The clinical presentation includes paradoxical pulse, hypotension, tachypnea, tachycardia, and peripheral edema. These symptoms and signs in patients with malignant disease should lead to immediate further evaluation to rule out the presence of pericardial effusion.
Author Disclosure Block:
V.M. Singh, None.