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Pericardial effusion in a patient with advanced lung cancer
The Journal of Emergency Medicine, Vol. 23, No. 4, pp. 409 – 411, 2002 Copyright © 2002 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/02 $–see front matter
PII S0736-4679(02)00604-2
Visual Diagnosis in Emergency Medicine
PERICARDIAL EFFUSION IN A PATIENT WITH ADVANCED LUNG CANCER Craig P. Adams,
MD
and Joseph W. Trachy III,
MD
Department of Emergency Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan Reprint Address: Craig P. Adams, MD, Department of Emergency Medicine, Sinai-Grace, Hospital, 6071 W. Outer Drive, Detroit, MI 48235
CASE PRESENTATION A 48-year-old man with a history of nonsmall cell-lung cancer presented with a complaint of dyspnea on exertion that had become progressively worse over the previous few days, and shortness of breath at rest which had been present for the past 12 h. The patient denied cough, orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, fever, or chills. He did complain of infrequent, intermittent, mild chest pain lasting one to two seconds and spontaneously resolving. The patient’s cancer had been diagnosed by biopsy approximately one year previously, and he had received radiation and chemotherapy. He had a 30-pack year smoking history, and family history revealed that his father had also developed lung cancer. On examination, the patient appeared in moderate respiratory distress, had a temperature of 38.1°C (100.5°F), blood pressure 115/70 mm Hg, pulse 112 beats/min, and respiratory rate of 24 breaths/min. Pulse oximetry was 100% on 10 liters O2 by face mask. The remainder of the examination revealed tachycardia with distant heart sounds, tachypnea, decreased breath sounds at the right base, and bilateral rhonchi. There was no JVD, no heart murmur, and the abdominal examination was unremarkable. The chest X-ray study (Figure 1) showed a moderate sized pleural effusion, moderate pulmonary vascular congestion, and a possible soft-tissue mass in the left mid-lung field. Blood gases showed pH 7.36,
Figure 1. Chest X-ray showing a moderate sized pleural effusion, moderate pulmonary vascular congestion, and a possible soft-tissue mass in the left mid-lung field.
pCO2 45 mm Hg, pO2 196 mm Hg, on a nonrebreather mask. Bedside ultrasound performed by the emergency physician revealed the presence of a moderate sized pericardial effusion (Figures 2 and 3) of no hemodynamic significance. The patient was subsequently admitted to the oncology service, with a consult to the cardiology service for two-dimensional echocardiogram, and cardiothoracic surgery for chest-tube placement.
RECEIVED: 18 September 2001; ACCEPTED: 19 February 2002 409
410
C. P. Adams and J. W. Trachy
Figure 2. Ultrasound showing four-chambered view of the heart with effusion (E) clearly visible anterior to the heart.
Figure 3. Ultrasound showing effusion (E) lying posterior to the left ventricle.
DISCUSSION Common etiologies of pericardial effusion include acute pericarditis, neoplasm (usually lung, breast, or lymphoma), renal failure, trauma, infection, and radiation. Less common etiologies include collagen vascular disease,
drug induced and post-myocardial infarction. Clinical signs are nonspecific and often difficult to assess, but include a quiet precordium, large area of precordial dullness to percussion, and Ewart’s sign (an area of dullness below the left scapula). Electrocardiogram may reveal electrical alternans (1,2).
Pericardial Effusion
The diagnosis is usually made after imaging study. Chest X-ray may show enlarged cardiac silhouette, and, rarely, the pericardium may be observed to be separated from the cardiac border. Echocardiogram is the imaging technique of choice. Effusions can be graded into small, with echo-free space visible only behind the left ventricle; medium, with free fluid visible anterior to the heart during systole; and massive, with large areas of free fluid visible around the heart in all cycles and in all projections (1,2). Signs of cardiac tamponade also may be observed. These include: first,
411
right atrial collapse; later, right ventricular collapse; finally, plethora of the inferior vena cava (3). REFERENCES 1. Braunwald E. Pericardial disease. In: Braunwald, E, ed. Harrison’s Principles of Internal Medicine, 15th edn. New York: McGrawHill; 2001:1365-72. 2. Shabetai R. Diseases of the pericardium. In: Alexander, RW, ed. Hurst’s The Heart, 9th edn. New York: McGraw-Hill, 1998:21692203. 3. Chan D. Echocardiography in thoracic trauma. Emerg Med Clin N Am 1998;16:191-207.
PII S0736-4679(02)00604-2
Visual Diagnosis in Emergency Medicine
PERICARDIAL EFFUSION IN A PATIENT WITH ADVANCED LUNG CANCER Craig P. Adams,
MD
and Joseph W. Trachy III,
MD
Department of Emergency Medicine, Sinai-Grace Hospital, Wayne State University, Detroit, Michigan Reprint Address: Craig P. Adams, MD, Department of Emergency Medicine, Sinai-Grace, Hospital, 6071 W. Outer Drive, Detroit, MI 48235
CASE PRESENTATION A 48-year-old man with a history of nonsmall cell-lung cancer presented with a complaint of dyspnea on exertion that had become progressively worse over the previous few days, and shortness of breath at rest which had been present for the past 12 h. The patient denied cough, orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, fever, or chills. He did complain of infrequent, intermittent, mild chest pain lasting one to two seconds and spontaneously resolving. The patient’s cancer had been diagnosed by biopsy approximately one year previously, and he had received radiation and chemotherapy. He had a 30-pack year smoking history, and family history revealed that his father had also developed lung cancer. On examination, the patient appeared in moderate respiratory distress, had a temperature of 38.1°C (100.5°F), blood pressure 115/70 mm Hg, pulse 112 beats/min, and respiratory rate of 24 breaths/min. Pulse oximetry was 100% on 10 liters O2 by face mask. The remainder of the examination revealed tachycardia with distant heart sounds, tachypnea, decreased breath sounds at the right base, and bilateral rhonchi. There was no JVD, no heart murmur, and the abdominal examination was unremarkable. The chest X-ray study (Figure 1) showed a moderate sized pleural effusion, moderate pulmonary vascular congestion, and a possible soft-tissue mass in the left mid-lung field. Blood gases showed pH 7.36,
Figure 1. Chest X-ray showing a moderate sized pleural effusion, moderate pulmonary vascular congestion, and a possible soft-tissue mass in the left mid-lung field.
pCO2 45 mm Hg, pO2 196 mm Hg, on a nonrebreather mask. Bedside ultrasound performed by the emergency physician revealed the presence of a moderate sized pericardial effusion (Figures 2 and 3) of no hemodynamic significance. The patient was subsequently admitted to the oncology service, with a consult to the cardiology service for two-dimensional echocardiogram, and cardiothoracic surgery for chest-tube placement.
RECEIVED: 18 September 2001; ACCEPTED: 19 February 2002 409
410
C. P. Adams and J. W. Trachy
Figure 2. Ultrasound showing four-chambered view of the heart with effusion (E) clearly visible anterior to the heart.
Figure 3. Ultrasound showing effusion (E) lying posterior to the left ventricle.
DISCUSSION Common etiologies of pericardial effusion include acute pericarditis, neoplasm (usually lung, breast, or lymphoma), renal failure, trauma, infection, and radiation. Less common etiologies include collagen vascular disease,
drug induced and post-myocardial infarction. Clinical signs are nonspecific and often difficult to assess, but include a quiet precordium, large area of precordial dullness to percussion, and Ewart’s sign (an area of dullness below the left scapula). Electrocardiogram may reveal electrical alternans (1,2).
Pericardial Effusion
The diagnosis is usually made after imaging study. Chest X-ray may show enlarged cardiac silhouette, and, rarely, the pericardium may be observed to be separated from the cardiac border. Echocardiogram is the imaging technique of choice. Effusions can be graded into small, with echo-free space visible only behind the left ventricle; medium, with free fluid visible anterior to the heart during systole; and massive, with large areas of free fluid visible around the heart in all cycles and in all projections (1,2). Signs of cardiac tamponade also may be observed. These include: first,
411
right atrial collapse; later, right ventricular collapse; finally, plethora of the inferior vena cava (3). REFERENCES 1. Braunwald E. Pericardial disease. In: Braunwald, E, ed. Harrison’s Principles of Internal Medicine, 15th edn. New York: McGrawHill; 2001:1365-72. 2. Shabetai R. Diseases of the pericardium. In: Alexander, RW, ed. Hurst’s The Heart, 9th edn. New York: McGraw-Hill, 1998:21692203. 3. Chan D. Echocardiography in thoracic trauma. Emerg Med Clin N Am 1998;16:191-207.