A 66-year-old Caucasian male was admitted due to chest pain, aggravated dyspnea, and productive cough. His symptoms started 15 days earlier and gradually progressed. He was a current smoker (30 pack/years) and his previous medical history included alcohol use, arterial hypertension, and chronic obstructive pulmonary disease (COPD). He had no history of congestive heart failure or dysphagia.
On admission the patient was pale, with dilated jugular veins, abdominal respiration with tachypnea (30 breaths/min), tachycardia (150 beats/min), and pulsus paradoxus (20 mmHg), while his blood pressure was with in normal range (100/60 mmHg). At auscultation, heart sounds were reduced and gallop rhythm was present; no murmurs or pericardial rub were audible. The chest examination revealed bilateral expiratory wheezing, that was attributed to the coexisting COPD. The abdomen was distended and the liver was palpable approximately 1 cm subcostally. The admission ECG showed sinus tachycardia with reduction of the amplitude of the QRS complexes and ST-segment depression in leads V4 to V6 (<1 mm). Chest X-ray demonstrated an enlarged cardiac silhouette, a small left lung lesion accompanied by a moderate pleural effusion on the left hemithorax and a minor one on the right, and elevation of the right dome of the diaphragm due to a calcified hepatic lesion (Figure 1). Arterial blood gas measurement revealed acute on chronic respiratory acidosis. Echocardiography revealed a significant pericardial effusion with compression of the right heart chambers. Due to his critical condition, an emergency pericardiocentesis was performed at the time of the admission. A quantity of 1100 cc of exudative bilious stained fluid was drained and his condition improved rapidly. Pericardial fluid showed total protein to be 2.2 g/dL, total bilirubin 4.7 mg/dL, indirect bilirubin 4.5 mg/dL and LDH 209 U/L, with absence of hemoglobin.
Chest CT-scan revealed a central mass of the left lung that was not prominent on the chest X-ray, a second smaller mass located in the left interlobar fissure, segmental atelectasis of the left upper lobe, a moderate pleural effusion on the left hemithorax and a small one on the right, a residual pericardial effusion, and a typical 9-cm hydatid cyst with calcified wall, located sub-diaphragmatically on the right lobe of the liver, in close contact with the diaphragm and the pericardial cavity (Figure 2).
A chest tube was inserted in the left hemithorax and 500 cc of sanguineous exudative fluid were consequently drained. In the complete blood count, white blood cells were 26,800/mm3 with marked neutrophilia (91.8%), whereas serum biochemistry values included glucose 234 mg/dL (normal range 70-110 mg/dL), total bilirubin 2.3 mg/dL (0-1 mg/dL), direct bilirubin 1.3 mg/dL, LDH 189 U/L (range 89-221 U/L), ALT 84 U/L (range 5-49 U/L), gamma-GT 96 U/L (range 0-53 U/L), CK 311 U/L (range 26-174 U/L) and CK-MB 33 U/L (range 0-24 U/L). The titer of anti-echinococcal antibodies was negative (Elisa, bioMerieux , titer of negative control <1:100). Culture of fluid from the left pleural and the pericardial effusion for common pathogens and Mycobacterium tuberculosis were negative. However, the cytology of the pericardial effusion was positive for non-small cell lung cancer (NSCLC), whereas the left pleural effusion was suspected for malignancy. Total bilirubin levels of the pericardial fluid were within normal range (0.5 mg/dL) after the third post-drainage day. Furthermore, no bilirubin was detected in the pleural fluid drained.
The chest tube was removed six days later after a successful slurry talk pleurodesis. A proper percutaneous subxiphoid pericardiotomy under local anaesthesia was performed one day later. Numerous local infiltrations on the pericardium and the myocardium were observed. Initially, drainage of 500-600 cc of fluid per day was observed, but with a diminishing trend. Pericardiodesis with bleomycin was performed and the pericardial drain was removed on the 10th post-pericardiotomy day. Histological examination of biopsies obtained from the resected pericardium revealed a metastatic poorly differentiated lung adenocarcinoma.
The patient was subsequently submitted to chemotherapy, but died 6 weeks later. During the follow-up no recurrent effusion was detected, clinically or radiologically. Unfortunately, the severe clinical condition of our patient did not allow us to investigate further the mechanism of pericardio-biliary communication. Postmortem examination was also not carried out.