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Case 22-2004: A 30-Year-Old Woman with a Pericardial Effusion

Case 22-2004: A 30-Year-Old Woman with a Pericardial Effusion

Case 22-2004: A 30-Year-Old Woman with a Pericardial

The new england journal of medicine case records of the massachusetts general hospital Founded by Richard C. Cabot Nancy Lee Harris, m.d., Editor Jo-Anne O. Shepard, m.d. , Associate Editor Sally H. Ebeling, Assistant Editor n engl j med 351;3 www.nejm.org july 15, 2004 Stacey M. Ellender, Assistant Editor Christine C. Peters, Assistant Editor Case 22-2004: A 30-Year-Old Woman with a Pericardial Effusion Edward A. Nardell, M.D., Dali Fan, M.D., Ph.D., Jo-Anne O. Shepard, M.D., and Eugene J. Mark, M.D. presentation of case A 30-year-old woman was admitted to the hospital because of fever, cough, shortness of breath, and a pericardial effusion. Approximately one month earlier, the woman had noticed an increased heart rate and fluttering in her neck when she bent over; both were relieved when she stood upright. During these episodes, her heart rate was 100 to 120 beats per minute. One week later, she noticed shortness of breath after walking up one flight of stairs. Since the age of 19 years, she had had intermittent atrioventricular nodal reentrant tachycardia, with heart rates of up to 180 beats per minute, and she had had approximately three episodes a year that resolved with the Valsalva maneuver. She had also had three episodes that had required visits to the emergency department and treatment with verapamil and adenosine. Because her current symptoms reminded her of these episodes, she consulted her cardiologist and wore a Holter monitor for a 24-hour period. No abnormal rhythms were revealed. One week later, the woman noticed increased fatigue, and several days later fever (temperature up to 38.0°C) developed, with a dry cough and increased shortness of breath. One episode of substernal chest pain occurred; it lasted 30 minutes and was relieved with acetaminophen. She visited her primary care doctor one week after this episode and was found to have anemia. The thyrotropin level was 0.65 µU per milliliter and the thyroxine level was 1.14 mg per deciliter (14.67 nmol per liter). Four days later, she went to the emergency department of another hospital because of persistent cough and fever (temperature up to 38.1°C). A chest radiograph showed a right pleural effusion and a possible infiltrate. A 10-day course of levofloxacin was begun. Two days later, the formal report of the chest radiograph was issued and noted an enlarged cardiac silhouette. An echocardiogram showed a pericardial effusion with right ventricular diastolic collapse — findings consistent with tamponade. She came to this hospital and was admitted. The patient was a physician in training. She did not smoke, drink alcohol, or use illicit drugs. A sister had Graves’ disease, and her mother had hyperthyroidism. Eleven months before admission, she had traveled to Nairobi, Kenya, for a month-long medical rotation. Since then, she had not traveled outside of the United States or to Martha’s From the Division of Pulmonary Medicine, Cambridge Hospital, Cambridge, Mass. (E.A.N.); the Departments of Cardiology (D.F.), Radiology (J.O.S.), and Pathology (E.J.M.), Massachusetts General Hospital; and the Departments of Medicine (E.A.N.), Cardiology (D.F.), Radiology (J.O.S.), and Pathology (E.J.M.), Harvard Medical School. N Engl J Med 2004;351:279-87. Copyright © 2004 Massachusetts Medical Society. The New England Journal of Medicine Downloaded from nejm.org by LOKESH VUYYURU on February 22, 2012. For personal use only. No other uses without permission. Copyright © 2004 Massachusetts Medical Society. All rights reserved. 279

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