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Beth Israel Deaconess Medical Center, Boston, MA
INTRODUCTION: Pericardial tamponade can be a life-threatening condition and has at its source multiple and varied causes. We report a case of purulent pericardial tamponade, caused by erosion of an infected hepatic cyst.
CASE PRESENTATION: A 69-year-old male with past medical history of hypertension, reflux disease, congestive heart failure, diverticulosis, chronic pancreatitis, polycystic kidney and liver disease, and end-stage renal disease, status post cadaveric renal transplant 5 years prior, presented to the emergency department with a history of 2 weeks of intermittent fever, chills, nausea and non-bilious vomiting. A previous admission, 8 months prior, had been for an infected liver cyst complicated with septicemia. In the emergency department, the patient became hypotensive, tachypneic and experienced worsening oxygen saturation. He was intubated for respiratory distress. A chest X-Ray showed an enlarged heart silhouette and left pleural effusion, while an echocardiogram showed right ventricular collapse and evidence of pericardial tamponade (Fig. 1). The EKG was normal. In the catheterization laboratory, 2 liters of purulent pericardial effusion was drained via pericardiocentesis. In order to achieve better drainage, the patient was, two days later, taken to the operating room for a pericardial window procedure and a left segmental liver resection. This liver segment contained the infected cyst that had eroded into the pericardium (Fig. 2). Both the fluid from the pericardium as well as the liver cyst showed microbiological evidence of Pseudomonas aeruginosa. The patient recovered from the hemodynamic and infectious standpoint and was transferred to the general surgical ward.
DISCUSSIONS: Pericardial tamponade can be classified into 4 subtypes as acute, subacute, regional and low pressure(1). On physical examination sinus tachycardia, increased jugular venous pressure, absence of an inspiratory decrease in jugular venous pressure (Kussmaul's sign), pulsus paradoxus (75%), and friction rub (30%) can all be appreciated. and may present with distant heart sounds ("quiet heart"), increased jugular venous pressure, and hypotension (Beck's triad). It can be diagnosed with transthoracic or transesophageal echocardiography, as well as computerized tomography (CT). CT imaging is not necessary if echocardiography is available. The echocardiogram can show diastolic collapse of the anterior right ventricular free wall, right atrial collapse, left atrial collapse (25% of patients) and very rarely left ventricular collapse. Inferior vena cava dilatation (i.e. no collapse on inspiration) and a "swinging heart" can be seen. Electrical alternans is a pathognomonic finding on the EKG.In the differential diagnosis the clinician should include acute coronary syndrome (ACS), aortic dissection, and congestive heart failure. ACS will have characteristic EKG findings, aortic dissection should not cause an increase in jugular venous pressure and neither is associated with pulsus paradoxus. Congestive heart failure can be differentiated by the use of echocardiography. Treatment can be achieved by catheter pericardiocentesis with echocardiographic guidance (class I recommendations by the European Society of Cardiology (2)), surgical pericardiectomy, which permits biopsies but exposes the patient to the risks of general anesthesia, and percutaneous balloon pericardiotomy, especially in patients with malignant effusions.In the published literature, most of the infectious causes of pericardial tamponade stem from hydatid cysts, either in the pericardium or from a nearby ruptured hepatic hydatid cyst. To our knowledge, this may be the first case of a non-hydatid infected hepatic cyst rupturing into the pericardium causing tamponade physiology. The treatment of pericardial tamponade from varied etiologies is similar and can lead to a favorable outcome.
CONCLUSION: Although rare, pericardial tamponade from a fluid-filled cystic structure as in this case can be caused by erosions of nearby structures. Timely diagnosis and treatment can result in favorable outcome.
DISCLOSURE: Andrew Miller, None.
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