A Case of Cardiac Tamponade Secondary to Malignant Effusion

History:

A 40-year-old man with no known past medical history presented with one week of fatigue and dyspnea on exertion. In the last week, the patient developed significant shortness of breath with only a few steps. The patient reported an unintended weight loss of 25 lbs in the last two months, as well as one month of intermittent epigastric abdominal pain and associated nausea. In the last week, the patient was seen by an outside clinic and diagnosed with H. pylori and started on treatment for H. pylori. He denies any other acute complaints or symptoms including orthopnea or paroxysmal nocturnal dyspnea.

Past Medical History:

None.

Past Surgical History:

Tympanoplasty (Left) (11/19/2021).

Social History:

No history of heavy alcohol use, tobacco use, or other recreational drug use.

Physical Exam:

Vital Signs: T 36.8, HR 133 RR 32, BP 121/59, SpO2 87% on room air, 94% on 5L NC

General:  Alert and oriented.

Eye:  Extraocular movements are intact. Normal conjunctiva.

HENT:  No oropharyngeal erythema, ulcerations, or exudate.

Neck:  No notable swelling or tenderness.

Respiratory:  Tachypneic, lungs are clear to auscultation.

Cardiovascular:  Tachycardic, regular rhythm, muffled heart sounds, no JVD.

Gastrointestinal:  Soft, non-tender, non-distended.

Integumentary:  Warm and dry, no rashes.

Extremities: No edema, cyanosis, or clubbing.

Neurologic:  Alert and oriented to time, person, and place.

Cognition and Speech:  Oriented, Speech clear and coherent. 

Psychiatric:  Cooperative, Appropriate mood & affect.

Initial Laboratory Results:

Leukocytosis (11), anemia (Hgb 9.9 with MCV 82), thrombocytosis (398), hyponatremia (130), hyperkalemia (5.1), LFT derangements (AST 349, ALT 253, Alk Phos 174), HAGMA with lactate of 7.6, troponin 0.069, and BNP 156. ANA, TSH normal.

CXR without consolidation or evidence of pulmonary edema. 

Index ECG:

Figure 2. Index ECG with evidence of low-voltage QRS.

Point-of-Care Echocardiogram:

Figure 3. Point-of-care echocardiogram with partially visualized right atrial lobulated mass (circled in red).

ECG after pericardiocentesis:

Figure 4. ECG after pericardiocentesis.

ED course and follow up care:

• In the ED, a point-of-care echocardiogram showed evidence of a large pericardial effusion with tamponade physiology. The Cardiology service was promptly consulted.

• The patient was taken to the cath lab for emergent pericardiocentesis and transferred to the CCU for further monitoring. In the cath lab, 1200 cc of bloody pericardial fluid were removed, and the patient’s heart rate improved from 124 to 97 bpm after the pericardiocentesis.

• Comprehensive echocardiogram and radiographic imaging after the emergent pericardiocentesis showed evidence of a diffuse gastric mass and lobulated mass of the right atrium concerning for cardiac metastasis. There was also evidence of an atrial defect caused by the cardiac mass with significant right-to-left shunting.

• Pericardial effusion cytology and biopsy of the gastric mass were positive for high-grade B-cell lymphoma.

• The patient’s hospital course was complicated by a DVT/PE and acute hypoxic respiratory failure secondary to right to left atrial shunting requiring intubation.

What clinical findings are present in cardiac tamponade?

• Based on a review of patients with cardiac tamponade, the most commonly reported symptom was dyspnea (66-90%), followed by chest pain. The most common exam finding was a heart rate greater than 100 bpm. (1)

• Beck’s triad is uncommon. In one ED-based study, no patients with tamponade had all three components present. (1)

• The most common ECG finding was tachycardia, followed by low voltage QRS. Electrical alternans was less commonly seen in patients. (1)

What is the differential diagnosis for a pericardial effusion?

• A pericardial effusion can be caused by essentially any condition that affects the pericardium, with the most common causes being the following:

  • Acute pericarditis (viral, bacterial, TB, idiopathic),

  • Malignancy,

  • Trauma/iatrogenic,

  • Autoimmune disease,

  • Post-myocardial infarction or cardiac surgery,

  • Mediastinal radiation,

  • Renal failure w/ uremia,

  • Myxedema, and

  • Aortic dissection extending into the pericardium. (2,3)

What ultrasound findings are consistent with cardiac tamponade physiology?

• Tamponade physiology occurs when the pericardial pressure is greater than the intracardiac ventricular pressure, therefore impeding filling of the right heart.

• Right ventricular collapse in diastole is the most specific (75-90%) finding of cardiac tamponade.

• Right atrial collapse in systole is the earliest sign of cardiac tamponade.

• A plethoric IVC with minimal respiratory variation has a high sensitivity (95-97%) but a low specificity (40%) for cardiac tamponade.

• Use tricuspid or mitral valve position to identify systole and diastole. M-mode can be used to more closely evaluate for right ventricular wall collapse during diastole. (4,5)

Take Home Points:

• The most common exam finding in cardiac tamponade is tachycardia. Beck’s Triad is uncommon.

• The differential for causes of a pericardial effusion is broad and includes infectious etiologies, malignancy, and trauma.

• RV diastolic collapse, RA systolic collapse, and a plethoric IVC are ultrasound findings consistent with cardiac tamponade physiology.

Authored by Alejandro Ruiz, MD.

Resources:

1. Alerhand S, Adrian RJ, Long B, Avila J. Pericardial tamponade: A comprehensive emergency medicine and echocardiography review. Am J Emerg Med. 2022;58:159-174. doi:10.1016/J.AJEM.2022.05.001

2. Pericardial effusion: Approach to diagnosis - UpToDate. Accessed January 12, 2024. https://www.uptodate.com/contents/pericardial-effusion-approach-to-diagnosis?search=pericardial%20effusion%20adult&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1107470359

3. Franz T, Young JS, Alerhand S, Koyfman A, Long B. Pericardial Effusion and Cardiac Tamponade: Pearls and Pitfalls - emDOCs.net - Emergency Medicine Education. Accessed January 12, 2024. http://www.emdocs.net/pericardial-effusion-and-cardiac-tamponade-pearls-and-pitfalls/

4. Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med. 2019;37(2):321-326. doi:10.1016/J.AJEM.2018.11.004

5. Alblaihed L. Differentiating pericardial effusion from pericardial tamponade on ultrasound. Accessed January 12, 2024. https://www.aliem.com/differentiating-pericardial-effusion-tamponade-ultrasound/