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

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280 The new england journal of medicine Vineyard, Massachusetts. A tuberculin skin test performed five months after she had returned from Africa was negative. She had had multiple exposures to children with viral illnesses in the course of her work. There was no history of rash or joint swelling. On physical examination, she appeared well. The blood pressure was 130/83 mm Hg, the heart rate 98 beats per minute, the respiratory rate 20 breaths per minute, and the temperature 36.1°C. There was a pulsus paradoxus of 8 mm Hg (140 mm Hg decreasing to 132 mm Hg). The hemoglobin oxygen saturation was determined by pulse oximetry to be 100 percent while the patient was breathing ambient air. An examination of the woman’s head, eyes, ears, nose, and throat showed no abnormalities. An examination of her neck showed a jugular venous pressure of 12 cm of water with bilateral carotid bruits and no lymphadenopathy. The breath sounds were clear. An examination of the heart showed no murmurs but did reveal a possible pericardial friction rub at the left lower sternal border. Abdominal and neurologic examinations showed no abnormalities, and the arms and legs were warm, with symmetric pulses and no edema. Laboratory test results are shown in Table 1. A chest radiograph disclosed small, bilateral pleural effusions and an enlarged cardiac silhouette (Fig. 1A). An electrocardiogram showed a normal sinus rhythm at 98 beats per minute; QRS intervals of 0.138, 0.075, and 0.405 second; a normal axis; diffuse T-wave inversions; and a downsloping J point in the V2 lead. An echocardiogram showed a large, circumferential pericardial effusion with right atrial inversion (Fig. 2), diastolic inversion of the right ventricular wall, and respiratory variation in the intracardiac flows — findings consistent with increased intrapericardial pressure. Pericardiocentesis was performed, and 370 ml of bloody fluid was removed. The pericardial pressure decreased from 7 to 0 mm Hg. A catheter drained decreasing amounts of fluid during the next 48 hours and was removed. A cytologic examination of the pericardial fluid showed blood and no malignant cells. A Gram’s stain showed red cells but no neutrophils or organisms, and a culture showed no growth of bacteria. A smear and a culture were negative for acid-fast bacilli and mycobacteria. An echocardiogram obtained on the second hospital day showed no reaccumulation of the pericardial effusion. The patient was discharged on the third day. A tuberculin skin test was performed during the hospitalization, and 16 mm of induration developed two days after discharge. n engl j med 351;3 Table 1. Laboratory Values on Admission.* Variable Value White-cell count (per mm3) 8,100 Differential count (%) Neutrophils 71 Lymphocytes 20 Monocytes 7 Eosinophils 1 Basophils 1 Hematocrit (%) 32.8 Hemoglobin (g/dl) 11.1 Platelet count (per mm3) 553,000 Mean corpuscular volume (µm3) 81 Sodium (mmol/liter) 136 Potassium (mmol/liter) 3.7 Chloride (mmol/liter) 105 Carbon dioxide (mmol/liter) 25.6 Calcium (mg/dl) 9.3 Phosphorus (mg/dl) 2.9 Magnesium (mg/dl) 1.8 Iron (µg/dl) 11 Iron-binding capacity (µg/dl) 227 Ferritin (ng/ml) 126 Rheumatoid factor (U/ml) Negative Antinuclear antibodies Positive (titer, 1:80); negative (titer, 1:160), with a speckled pattern Anti–double-stranded DNA Negative (titer, 1:10) antibodies * To convert the value for calcium to millimoles per liter, multiply by 0.250. To convert the value for phosphorus to millimoles per liter, multiply by 0.3229. To convert the value for magnesium to milliequivalents per liter, divide by 0.5. To convert the values for iron and iron-binding capacity to micromoles per liter, multiply by 0.1791. Echocardiograms obtained one and two months after discharge showed a minimal pericardial effusion, diffuse fibrin deposition on the visceral pericardium, and no evidence of tamponade. Two months after discharge, the patient was seen in the pulmonary clinic for evaluation of the positive tuberculin skin test. On physical examination, the lungs were normal on auscultation. Smears and cultures of three specimens of sputum were negative for acid-fast bacilli and mycobacteria. A radiograph of the chest showed resolution of the pleural effusions but two new, small nodular opacities in the right upper lung zone (Fig. 1B). Computed tomographic (CT) scanning of the chest, performed with- www.nejm.org july 15, 2004 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.
A B Figure 1. Chest Radiographs. case records of the massachusetts general hospital On a chest radiograph obtained on admission (Panel A), there are small bilateral pleural effusions and an enlarged cardiac silhouette. A chest radiograph obtained two months after discharge (Panel B) shows resolution of the pleural effusions and the development of new, small nodular opacities in the right upper lobe. out the intravenous administration of contrast material (Fig. 3A and 3B), showed a cluster of small nodules, 3 to 5 mm in diameter, in the right upper lobe, as well as multifocal mediastinal lymphadenopathy, a confluent mass of subcarinal lymph nodes, and an enlarged right hilar lymph node. There was minimal pericardial thickening and slight thickening of the right posterior pleura. One week later, bronchoscopy was performed, n engl j med 351;3 E A B C Figure 2. Echocardiograms Obtained on Admission. In an apical four-chamber view (Panel A and Video Clip 1 of the Supplementary Appendix), there is a large pericardial effusion (bar) and inversion of the right atrium (arrow), caused by elevated pericardial pressure, in late diastole and early systole. A parasternal short-axis view (Panel B and Video Clip 2 of the Supplementary Appendix) shows that the right ventricular outflow tract is compressed in diastole because of the elevated pericardial pressure (arrow). The bar shows the pericardial effusion. A Doppler study of flow across the mitral valve (Panel C) shows respiratory variation in the mitral inflow E wave, a sign of tamponade. The arrowheads denote expiration, the asterisks inspiration, E diastolic mitral E wave, and A diastolic mitral A wave. The scale to the right indicates flow velocity, measured in centimeters per second. www.nejm.org july 15, 2004 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. A * * 281
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Case 22-2004: A 30-Year-Old Woman with a Pericardial Effusion

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