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Forum Name: Pericardial Diseases

Question: rapidly progressive pericardial effusion


 wafaa - Sun Dec 28, 2008 3:08 pm

my aunt is 41 years old, with no past history or family history of cardiac disease,
she had severe right hypocondrial pain, dry cough, and dyspnea, orthopnea and sweating with no fever. she went to the doctor who gave her voltarin ampule and buscopan ampule and oral antispasmotics.
2 days later the pain became diffuse upper abdominal, with severe pain attacks up to vasovagal shock that are not related to meals or ceartain posture and realived without medications within 5minutes.
she had an abdominal u/s showing mild liver enlargement, and mild ascitis,
and liver function tests were normal.
she was not realived by the medication so, she went to a hospital were her blood preseaure was 80/50, so she became an inpatient, after medical examination in out clinic, for more investigations.
they gave her 500ml saline IV, a surgical consultant transfered her to the CCU, where they gave her adrenaline inffusion, sodium bicarbonate and saline through a central venous line. during that, she developed severe dyspnea, echo diagnosed cardiac tamponade. pericardiocentesis was done revealing 1200ml hemarrhagic effusion,and she improved, but 6 hours later she developed cardiac tamponade again but nothing came by the drain.
investigations revealed: brolonged prothrombin time, low albumin, elevated liver enzymes, and heamoglobin 9, ceriatinin 2.4
they gave her 1.5 liters blood, and plasma.
then she had pericardial window and biopsy and introduced pleural tube for drainage next day.
then she developed severe dyspnea within hours after the operation, she was put on ventilator, CT chest showed bilateral consolidation of the lungs with areas of injury and fibrosis, diagnosed as postoperative pneumonia and ARDS.
biopsy and citology showed non specific mesothelial hyperplasia.
would you kindly give me your openion about diagnosis and treatment.
thank you
 John Kenyon, CNA - Mon Dec 29, 2008 11:59 pm

User avatar Hello -

FIrst, the early workup of your aunt should have at least been suggestive of pericardial tamponade. The liver enlargement with mild ascetes yet normal liver function tests should have caused suspicion of tamponade early on. Later elevated liver enzymes were to be expected. A good opportunity to discover the suspect tamponade would have been to perform an echocardiogram earlier in the process, but since the problem apparently wasn't suspected, this opportunity to avoid a critical situation was missed.

The most common causes of pericardial tamponade are kidney failure, cardiac trauma (via chest injury or medical catheter mishap, neither of which would appear to be a factor here), connective tissue disease and some cancers. There's no obvious link to any of these, but because of that the suspicion would fall to the most insidious probable cause which, in your aunt's case would be an undiscovered malignancy or connective tissue/autoimmune disease (lupus, for example).

It's impossible to determine here what the underlying cause of the primary problem is, but one would hope all the requisite explorations are being pursued now by your aunt's doctors.

I hope your aunt receives appropriate care and begins to improve. Please keep us updated as to her progress. I hope this response is helpful to you.
 wafaa - Thu Jan 01, 2009 5:05 pm

thank you very much for caring and the reply dr.Kenyon
as regard her chest condition, after 3 days on ventilator, she got better and there is no dyspnea now and no recollection of effusion hapened in pleura or pericardium since the operation.
but due to her low coagulation profile, the ICU doctors gave her packed RBCs and platelets despite the refuse of her cardiologist.
3days she started to complain from pain in her both lower limbs, after a dopler, they discovered thrombi formation in both iliac veins, so they started to give her medications for that, but then next day they discovered thrombi in her left axillary vein and later that day they found another 2 in her brain, she is now suffering from right hemiplegia and affection of her left side of her face and she is having a mood disturbance, but she is conscious and speaking but some times she says some unrelevant words just for seconds then she is fine.
she had a lot of immunological and rheumatological investigations daily, all turned negative.
citology and pathological analysis of the sample were unconclosive(non specific mesenchymal cells) , but they are reexamining again.
dopler was made again with CT, showing no mare thrombi were formed and no bleeding
wold you please tell me what conclusive investigations should be done to exclude malignancy? and can it be a viral infection or idiopathic cause? and when can she leave the ICU she has been there now for 2 weeks and she wants to get out?
thanks for your kind reply and we realy apreciate your concern
thanks

 John Kenyon, CNA - Fri Jan 02, 2009 11:50 am

User avatar I'm happy to hear the positive news, but distressed about the unfortunate ensuing events. It would seem she has a clotting disorder, and while this may be secondary to an occult malignancy it is more likely, now that this has happened, that it is probably a heritable genetic defect. She hopefully has been tested for such things as Factor V Leiden, etc. As for conclusive investigations to exclude malignancy, that's a subject out of the scope of my knowlege and training, but I can certainly pass this question along to our oncology team and see if anyone has any suggestions toward that end. There are some blood tests that can at least suggest the presence of tumors such as CA 19.9, a tumor marker test, which can at least, hopefully, disclose the presence of any tumors.

I hope this is helpful and also hope your sister will recover from the stray thrombi as quickly as she recovered from the pericardial effusion. She seems to be intrinsically strong, so that's a positive for her. My best to you both, and please keep us updated.
 wafaa - Tue Jan 06, 2009 4:52 pm

thank you dr.Kenyon for your quick response.
those investigations you mentioned and the rest of rheumatological and tumor markers were done to her and they all turned negative that's why her doctor is sugesting a viral infection or ediopathic cause as there is also no sugestive family history of such case.
about the thrombosis, could it happen because she is bed ridden and they gave her extra packed RBCs, platelets, and albumin?
can her pericardial effusion return at any time? or can she have any kind of cardiac complications as constrictive pericarditis or something?
and how can we follow up her case, like certain symptoms that could suggest a relapse so we can save her with least complications?
thank you for your helpful advice
happy new year

 John Kenyon, CNA - Wed Jan 07, 2009 12:24 pm

User avatar Hello again -

Since all the heritable disorders and mutations seem to have been ruled out, which is a good thing actually, the burden of likelihood shifts to a reaction to the packed RBCs (not necessarily the albumin) due to some odd and unpredictable factor. This is fairly unusual, but it can and does happen. A viral cause is also possible, but less likely. "Idiopathic" simply means "no known cause can be determined." This may wind up being the diagnosis of record, but hopefully someone will retrace the history of the packed cells if possible, just to be sure there wasn't some incompatability that wasn't caught on first screening.

If there should be a relapse it won't have been the packed RBCs, so the detective work would have to start over, and let's hope that doesn't happen, but in the meantime the things to look for would be signs of anemia (weakness, fatigue, pallor) first and foremost, and if the source of bleeding inside the pericardium remains patent, then also of course signs of a return of pericardial tamponade should be noted and reported at once. That would include frank chest pain (usually of a sharp nature and often affected by position), difficulty breathing, and pleuritic pain upon breathing. If any of these things are noted someone should contact the doctor at once.

I hope this is helpful and that she continues to improve and experiences no further problem of this sort. Best of luck to all there, and please keep us updated.
 wafaa - Thu Jan 15, 2009 11:23 am

thanks dr.Kenyon
she finally left the hospital, the final CT brain and dopler showed that the clots have disolved and the only thing found in brain(parietotemporal) is an inflamation in the area of thrombus and they say that it is regressive and it is getting better, but clinically we can not see any improvement.
can you kindly tell me the prognosis of her hemiplegia and the posibility of her regaining her motor action of her affected limbs? (sensations are normal)
sorry for bothering you again, but is it advisable to give 16 fresh frozen plasma, 8 fresh blood paks, and 2 paks of platelets and 24 ampules of vitamin k, to her for 5 days and she was bed riddin, and her heamoglobin was 7.2 gm/dl and prothrombin time 21.6 and improving to heamoglobin 12.8 and prothrombin time 16.5 (in the day they discovered the thrombosis) and there was no bleeding?
and does the tube of the central venous line reach the heart?
thank you very much for your help and consultation and caring

 John Kenyon, CNA - Thu Jan 15, 2009 12:28 pm

User avatar Hello -

There is a lot of good news here. I'm so glad she's out of the hospital and that the inflammation in the area where the thrombus had lodged is regressing. It seems likely she'll be making a full recovery if there are no further events.

The question regarding the infusions of plasma, platelets, vitamin K, etc., is a difficult one to answer without having been in attendance, but since she is doing well I would trust this was intended to offset effects of the prior bleeding and to help avoid any future bleeding events. We must assume this was the prudent approach.

Regarding the central line, depending upon the type and the insertion site, as well as the intended purpose, yes, sometimes a central line may reach into the right atrium of the heart. At other times it rests in the superior vena cava. In either case complications involving the heart are extremely rare. When the line is placed in the right atrium this is usually for purposes of measuring closely capillary wedge pressures with extreme accuracy. If there is a central line still in place, I doubt it would be left in that location, but probably would be backed out or changed to the vena cava. Of course it may have been removed prior to discharge.

I continue to hold good thoughts for her recovery and am sure she will be appreciative of having had such great support and advocacy from you and the rest during this ordeal. My best to you all.

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