A 19 years old man with a history of migraine and smoking, was admitted to emergency service with abdominal pain, nausea, dyspnea
and loss of appetite for one week. The abdominal pain was worsening by standing and it was relieving by lying down. He had prodromal period symptoms for ten days. Chest x-ray revealed minimal cardiac silhouette enlargement. As computerized tomographic (CT) scan of abdomen and thorax revealed large amount of free peritoneal, 30 mm pericardial, 30 mm pleural effusion in left lung as well as 20 mm effusion in right lung, he was consulted to our department. Electrocardiogram showed sinus tachycardia. Transthoracic echocardiography (TTE) showed large circumferential pericardial effusion (PE) with right atrial (RA) and right ventricular (RV) diastolic collapse and >30% variation in mitral inflow pattern suggesting cardiac tamponade (Figure 1)
. He was hypotensive and tachycardic during examination; pulsus paradoxus was observed at the same time. It was concluded that the most convenient way for PC was apical approach.
However collecting very small amount of pericardial fluid (15 cc), his hemodynamic profile was rapidly improved. A CT scan of thorax was taken immediately and 15 mm residual pericardial effusion was implemented; but 20 mm effusion at right and 45 mm at left lung was identified (Figure 2). Thoracal drainage tube was inserted left pleural cavity and 500 cc hemorrhagic fluid drainage was collected. Tube was removed 2 days after, and no residual or recurrent effusion existed in his control radiologic examination. Increase in acute phase reactants like, CRP:93(0-5mg/l) fibrinogen:744 (200-400mg/dl), ESR: 53mm/h and neutrophilic leucocytosis was established in blood tests. However pericardial effusion was exudative quality; aerob- anaerob blood, urine and fluid culture was negative, no acid fast bacilli was seen in fluid, ANA, Anti-CCP, Anti-DNA and ENA profile were also normal.
Colchicum 2*5mg and brufen 3*600 mg without antibiotic regimen applied as the treatment strategy. 10 days after beginning of the treatment, only 10 mm pericardial effusion at posterior wall and 8 mm at RV neighbouring found in TTE (Figure 3). He was on treatment for two months without any symptoms; rheumatologic and genetic tests are still having been done.
Cardiac tamponade is a life-threatening condition and requires emergent treatment. A variety of percutaneous or surgical therapeutic methods have been applied. Pericardiosyntesis is a minimally invasive, easy to perform procedure and has relatively shorter inhospital stay and lower complication rate than surgical operation. Apical, subxiphoid and other sides are area of interest in procedure. In our clinic, most of the PC are done by apical approach with lower complication rates. In this case, a complication happened during emergent PC which is likely to occur. Despite symptomatic and haemodynamic relief of patient, immediate echocardiographic study and CT scan was taken due to continuing of clinical suspicion. Thoracal drainage tube inserted fastly as a result of increase in left pleural effusion.
We think that increase in the amount of pleural fluid is an acceptable result confronting with the life threatening feature of tamponade. Mutual result of tamponade, haemodynamic parameters, clinical backround of patient as well as collaborative assesment of imaging techniques are contributing to the outcome.