A 31-year-old South Asian man with no significant medical history presented to the emergency department with a 1-week duration of worsening dyspnea. He did not report any angina, orthopnea, paroxysmal nocturnal dyspnea, or syncope. His social history revealed that he vaped large quantities of cannabis daily (half of a cartridge:1.5 mg, 95% tetrahydrocannabinol) or the prior 2 months without tobacco, alcohol, or illicit drug use. He did not have any recent travel history, nor did he have any pets. He did not display any antecedent viral symptoms and denied any sick contacts.
On admission to the emergency department, his vital signs included a blood pressure of 115/82 mmHg, a pulse of 88 beats per minute, and regular pulse oximetry of 98% on ambient air. On physical examination, he appeared comfortable without cardiopulmonary distress, with a mildly distended jugular venous pressure of 9 cm of water, and normal heart sounds without a pericardial friction rub on auscultation. He had no crackles upon auscultation of the lung fields, and no peripheral edema was noted.
His electrocardiogram revealed sinus rhythm, a rate of 83 beats per minute with small voltage complexes, and nonspecific ST-T changes such as T-wave inversions in leads V5-V6, II, III, and (aVF) (Figure 1). The chest radiograph did not indicate any acute cardiopulmonary disease. Pertinent diagnostic laboratory investigations revealed a normal troponin I 0.05 ng/mL (normal range: 0.0-0.08 ng/mL) and NT-pro-brain natriuretic peptide 105 pg/mL (normal range < 125 pg/mL). His complete blood count, renal, hepatic, and thyroid function tests were normal. A glycosylated hemoglobin and lipid panel were also normal. A 2-dimensional transthoracic echocardiogram (2D-TTE) revealed a moderate circumferential pericardial effusion ("anterior" dimension of 13 mm, "posterior" dimension of 8 mm) with no impending tamponade physiology and preserved left ventricular function (Figure 2).
He was admitted to the cardiology ward and was administered high-dose aspirin (325 mg every 8 hours), colchicine (0.5 mg every 12 hours), and pantoprazole (40 mg every 12 hours). No oral or intravenous glucocorticoids were administered. Diagnostic pericardiocentesis was not performed as there was no evident tamponade physiology, and it was not deemed in the patient's risk-benefit favor. During his ensuing 1-week hospitalization, he remained hemodynamically stable, and a repeat 2D-TTE indicated a significant interval improvement in the pericardial effusion (Figure 2). No pericardiocentesis or advanced thoracic imaging was performed.
Further detailed work-up included a negative interferon-gamma release assay (QuantiFERON-TB Gold Plus), hepatitis panel, HIV, enzyme-linked immunosorbent assay (ELISA), RNA, polymerase chain reaction (PCR), and respiratory pathogen panel (BioFire) tests. Inflammatory markers (erythrocyte sedimentation rate and high-sensitivity C-reactive protein) were normal. A comprehensive rheumatologic and immunologic panel was unremarkable. Coronavirus 2019 PCR and rapid antigen tests were negative, in addition to blood cultures and urinalysis. He was extensively counseled with respect to the possibility of his cannabis vaping being implicated in the etiology of the pericardial effusion and subsequently discharged for routine outpatient follow-up with a surveillance 2D-TTE.