A 63-year-old woman was referred to our intensive care unit for acute pericarditis. The patient had no history of smoking, systemic diseases or cancer. Five days prior to her referral, she had been admitted to another hospital for acute pericarditis with an echocardiogram that showed a pericardial effusion, and 200ml of non-coagulable bloody fluid was removed. Her symptoms had reportedly started four weeks earlier, when she began to complain of weakness, progressive dyspnoea and chest pain.
She was confused when she arrived in our department. A cursory physical examination revealed a congested jugular and oedema in the lower extremities. Blood pressure was low (80/60 mmHg), with an increased heart rate (110/min) and distant heart sounds without a pericardial rub or paradoxical pulse. The electrocardiogram showed prominent low voltage QRS complexes in all derivations. Two-dimensional echocardiography showed a large pericardial effusion and marked diastolic collapse of the right auricular (Figure 1) with significant respiratory variation in mitral flow velocity (Figure 2), there was no collapse of the right ventricule.
Emergency pericardiocentesis was performed via a subxiphoid approach. After the removal of 350ml of non-coagulable bloody fluid, clinical symptoms rapidly improved and her blood pressure rose to 100/60mmHg. A post pericardiocentesis echocardiography showed a high pulmonary artery systolic pressure with pulmonary artery systolic pressure at 50 mmHg.
A chest radiograph revealed an enlarged cardiac silhouette, bilateral pulmonary interstitial infiltrates, and a small bilateral pleural effusion.
Laboratory results showed an elevated erythrocyte sedimentation rate of 50mm/h, protein C reactive at 130 mg/l, and a white cell count of 12,000/mm3. Cancer antigen 19-9 (CA), CA 125 and CA15-3 analysis revealed very elevated levels. Systemic diseases and tuberculosis were excluded.
A computed tomography scan was performed to identify the origin of pulmonary hypertension, it revealed a mass lesion in the right lower lung lobe (2.1cm), with pleural effusion and bilateral proximal pulmonary embolism (Figure 3). A lung mass biopsy with histo-pathological examination revealed primary moderate differentiated adenocarcinoma. The patient received anticoagulation therapy and was referred to the department of oncology.
A chest computed tomography scan showing mass lesion in the right lower lung lobe (arrow), and bilateral proximal pulmonary embolism (PE).