Hypotensive presentation of cardiac tamponade can simulate Addisonian crisis.

Cardiac tamponade is a medical emergency. This study was carried out to determine the etiologies of cardiac tamponade and review the management and outcomes. We retrospectively analysed case records of patients who underwent pericardiocentesis for cardiac tamponade during the two consecutive years (1 January 2018 to 31 December 2019) at Hospital Sultanah Nora Ismail, Batu Pahat, in Johor, Malaysia. There were ten patients (eight males, two females; age range 20 to 70 years old, mean age 36 years old) who underwent pericardiocentesis for cardiac tamponade during the said period. Malignancy (40%), tuberculosis (30%), idiopathic (20%), and bacterial (10%) were among the common causes of the pericardial effusion in this center. The commonest symptoms were breathlessness (90%), chest pain (60%), cough (50%), and unexplained fever (20%). Pulsus paradoxus was the most speciÿ c sign (100%) for the presence of echocardiographic feature of cardiac tamponade. Two of the patients with tuberculous pericarditis had retroviral disease; one patient had bacterial pericarditis due to salmonella typhi. This study has conÿ rmed that there are many etiologies and presentation of cardiac tamponade; clinicians should be alert as urgent pericardiocentesis is lifesaving.

Neoplastic pericarditis can be presented as acute pericarditis, pericardial effusion, effusive constrictive pericarditis or cardiac tamponade. For the majority of patients, a clinical manifestation of neoplastic pericarditis is absent or remains unrecognised during their life. A 56 year old male asymptomatic until three days ago that began with intense pain in epigastric region . The yugular vein was distended, breath and heart sounds were slightly decreased. Right-sided abdominal pain especially pronounced in the epigastric and right iliac fossa, his liver was palpable 2 cm below the right costal margin. In first cut of abdominal CT we showed pericardial effusion . The patient improved immediately after thetherapeutic pericardiocentesis. For the study of primary tumor was performed a thoraco-abdominal CT. Showing right hiliar mass, mediastinal lymph nodes, bilateral lung metastases. The patient was diagnosed with stage IV lung carcinoma, initiated the chemotherapy treatment (carboplatin-gemcitabine) by the medical oncology service at our hospital. Cardiac tamponade as the initial manifestation of malignancy is rare and such patients have a very limited expectancy, is because at the time of tumor disease diagnosis it is already advanced . There are few reported cases of patients with pericardial tamponade who presented with abdominal pain. J Med Cases. 2013;4(7):488-490 doi: http://dx.doi.org/10.4021/jmc1213w

Disclosure: A. Farooq: None. A. Ghumatkar: None. J. Snitzer: None. Introduction:Cardiac tamponade, a life-threatening emergency, can be associated with primary adrenal insufficiency (Addison Disease), and accurate diagnosis requires a high degree of clinical suspicion in patients with uncertain etiology and nonspecific signs and symptoms. Case Presentation:A 58-year-old female with a history of Hashimoto thyroiditis was evaluated in the hospital for two episodes of cardiac tamponade requiring emergent pericardiocentesis within one month. The patient had been experiencing symptoms of fatigue, nausea, lightheadedness, dizziness, hiccups, and tanned skin for the past year. She also had a recent flu-like illness with nausea and vomiting four months before her current presentation. Her vitals were notable for hypotension during these episodes. Her lab work showed hyponatremia (128 mEq/L, reference range: 136-145 mEq/L) with normal potassium and glucose levels. Her thyroid function tests were within normal limits on her home levothyroxine dosage (TSH 4.588 IU/ml, reference range: 0.5-8.9 IU/ml). An ACTH stimulation test was performed based on the patient's clinical presentation, consistent with adrenal insufficiency. Her baseline cortisol level was 5.9 mcg/dL (reference range: 6.7-22 mcg/dL), a post-ACTH stimulation level of 6.7 mcg/dL after 30 minutes, and 6.0 mcg/dL after 60 minutes. Her 21 alpha-hydroxylase antibody titer was also positive for Addison Disease (231U/mL, reference range <1 IU/mL). A CT scan of the abdomen with intravenous contrast was done, which revealed no abnormality of the adrenal glands. She was treated with stress doses of hydrocortisone during hospitalization and discharged with maintenance dosage and follow-up with endocrinology. She had another episode of acute adrenal crisis about a month later but had no pericardial effusion this time and responded well to the treatment with stress doses of steroids. She has remained healthy at 14 years of follow-up. Conclusion: This case emphasizes the need to consider adrenal insufficiency in the evaluation of cardiac tamponade or pericardial effusions, especially in patients with existing autoimmune glandular disorders. This patient may have autoimmune polyglandular syndrome type 2 (APS-2), which is a cluster of two or more endocrine glandular disorders primarily diagnosed in adulthood and predominant in females. The risk of adrenal crisis is more than twofold in Addison disease due to APS-2. Lastly, this case highlights that hiccups can be related to adrenal insufficiency, with pathophysiology possibly involving diaphragmatic irritation due to adrenal inflammation that resolves with treatment. Presentation: 6/3/2024

Cardiac tamponade presenting as leg swelling

Although tuberculosis (TB) figures among the top 10 causes of mortality globally, it is rather infrequently encountered in the intensive care unit (ICU) setting even in countries where TB is widely prevalent. Patients with TB constitute less than 2% of total ICU admissions (Muthu et al. 2018; Frame et al. 1987). Notwithstanding, these patients pose considerable challenges in terms of timely diagnosis, treatment, and infection control. Patients with clinically severe forms of TB may require admission to the ICU. Studies from various settings indicate that a broad range of 1–25% of patients with active TB require ICU admission (Patel et al. 2017; Tsai et al. 2008; Levy et al. 1987; Lui et al. 2014; Eveloff et al. 1994; Rao et al. 1998; Silva et al. 2010). The most common reason for transferring a patient with active TB to the ICU is acute respiratory failure (ARF) (Muthu et al. 2018; Frame et al. 1987; Zahar et al. 2001; Valade et al. 2012). Other common indications include mycobacterial septic shock and multiorgan dysfunction syndrome (MODS). However, in some settings, TB meningitis is the most common reason for ICU admission among TB patients. About 40% of patients with TB meningitis would have concomitant pulmonary disease. Less common indications could be massive hemoptysis, pericardial effusion causing cardiac tamponade, Addisonian crisis, airway obstruction in laryngeal TB, disseminated intravascular coagulation (DIC), and seizures caused by tuberculomas in the brain. Importantly, TB patients may also experience acute liver failure due to hepatotoxic drugs and rarely acute renal failure, mainly rifampicin-induced (Hagan and Nathani 2013) (Table 16.1).

BackgroundAdrenal crisis is an acute life-threatening exacerbation of the Addison’s disease or primary adrenal insufficiency (PAI) and is associated with a high mortality rate. It can be the first manifestation of adrenal insufficiency and is caused by a critical lack of glucocorticoids.Case summaryHere, we report the case of a 19-year-old woman presenting to the emergency room with unspecific symptoms, i.e. lethargy, fatigue, arthralgia, dyspnoea, and hypotension. The patient’s examination showed major pericardial effusion resulting in cardiac tamponade requiring immediate pericardiocentesis. In the further course, acute right heart failure and progressive cardiogenic shock occurred. Due to recurrent bradycardia and finally asystole, the patient had to be resuscitated for 15 min in total until return of spontaneous circulation. However, non-invasive haemodynamic stabilization of the patient was not successful. Hence, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was used as salvage intervention to provide temporary circulatory support. We diagnosed an Addison crisis as first manifestation of her previously unknown Addison’s disease. An appropriate substitution therapy with hydrocortisone and fludrocortisone was immediately initiated and the patient’s condition rapidly improved. After a total in-hospital stay of 4 weeks, she recovered completely and could be discharged from hospital.Discussion An Addison crisis requires rapid diagnosis and immediate treatment to end a life-threatening condition caused by critical glucocorticoid deficiency. In patients with non-specific symptoms, such as fatigue, hypotension, weight loss, and hyponatraemia, adrenocortical insufficiency should be considered as differential diagnosis. If patients suffer from an Addison crisis, clinical suspicion requires immediate substitution of hydrocortisone as this is essential for patient’s survival. Venoarterial extracorporeal membrane oxygenation therapy can serve as a bridge to diagnosis and effective treatment in patients requiring temporary cardiopulmonary support, especially as salvage intervention for patients in cardiogenic shock. To our knowledge, this is the first case of a young patient with acute Addison crisis and cardiogenic shock, who was successfully salvaged by VA-ECMO support.

Introduction: Acute liver injury (ALI) has an extensive differential diagnosis list which can make diagnosis challenging. A few causes of elevation of AST (aspartate transaminase), ALT (alanine transaminase) in thousand is ischemic, toxic and viral hepatitis. One such rare cause is cardiac tamponade that can present as an acute liver injury. The literature of cardiac tamponade causing ALI is limited to few case reports and we present one such case. Case Description/Methods: A 55 year old male with squamous cell lung cancer on durvalumab, diabetes mellitus presented with worsening shortness of breath for the last one week. On presentation his vitals were stable and physical exam revealed distant heart sound with electrical alternans noted in electrocardiogram. Blood work was noted for elevated ALT 1481 U/L (units per liter), AST 803 U/L, ALP (alkaline phosphatase) 227 U/L, total bilirubin 1.3 mg/dl. Patient has had a normal LFT (liver function test) in blood work done 3 weeks ago. Initial chest x-ray showed large right pleural effusion. The next day, repeat lab revealed worsening of liver enzymes with INR (international normalized ratio) 3, ALT 4146 U/L, AST 4302 U/L, ALP 189 U/L, total bilirubin 2 mg/dl and LDH (lactate dehydrogenase) 3879 U/L. Serum creatinine was also noted to worsen to 2.06 mg/dL from baseline 0.89 mg/dL. CT chest revealed large right sided pleural effusion with possible underlying pneumonia or atelectasis in the right middle and lower lobe with moderate to large pericardial effusion. Patient underwent an echocardiogram which revealed a 3.1 cm circumferential pericardial fluid collection with tamponade physiology. He was taken for urgent pericardiocentesis with removal of 760 mL of fluid. Pericardial fluid cytology revealed adenocarcinoma. Post pericardiocentesis patients LFT improved and he was discharged after 6 days (Figure). Discussion: ALI can be a presenting sign of cardiac tamponade, a prompt diagnosis and treatment can be life saving. Cardiac tamponade is thought to cause liver injury by hepatic venous congestion and decreasing cardiac output causing ischemic Injury. 50% cases of ischemic hepatitis do not have documented hypotension. A few lab abnormalities often seen with ischemic hepatitis are acute kidney injury, massive rise in LDH, hyperglycemia. The prognosis of ischemic hepatitis depends on the inciting cause rather than severity of liver injury. A 50% improvement in liver enzymes within 72 hour of correction of inciting cause is usually seen.Figure 1.: Electrical alterans.

Cardiac tamponade is a recognised complication of blunt trauma to the chest. It usually presents at the time of the acute event but there are rare cases of delayed presentations. We present such a case where the tamponade occurred six weeks following the trauma to the chest wall.

A 62-year-old man presented with 2 weeks of progressive dyspnea and chest pain. He was previously diagnosed with high-grade invasive urothelial carcinoma (UC) of the bladder and underwent neoadjuvant chemotherapy followed by radical cystectomy 10 months earlier, resulting in pathologic complete remission. Clinical evaluation and echocardiographic imaging was consistent with a diagnosis of cardiac tamponade. Due to a history of malignancy, the patient was referred for a surgical pericardial window, to include biopsy of the pericardium. Pericardial fluid and pericardial biopsy specimens were consistent with metastatic UC. Cardiac tamponade due to metastatic UC is a rare presentation, and, to our knowledge, there have been only 5 cases reported in the English literature. We report a rare case of cardiac tamponade due to isolated pericardial metastases from high grade UC of the bladder and discuss the symptoms, treatment, and prognosis of this pathologic condition. We also present a brief review of previously published literature. Through this discussion, we would like to emphasize the (1) consideration of cardiac metastases in the differential diagnosis for patients with a history of UC presenting with cardiac or pulmonary symptoms and (2) improved diagnostics with pericardial biopsy and pericardiocentesis over pericardiocentesis alone.

Cardiovascular effects of hypothyroidism include bradycardia, diastolic hypertension, atrial fibrillation, prolonged QT interval leading to torsades de pointes, varying degrees of AV block, accelerated coronary artery disease, and pericardial effusion. Cardiac tamponade is rare in patients with hypothyroidism because of pericardial distensibility and slow accumulation of fluid. The amount and rate of accumulation of pericardial effusion are related to the severity of hypothyroidism. Though rare, significant pericardial effusion can be a manifestation of subclinical hypothyroidism.