A five-year-old child, body weight 23 kg, with acute cardiac tamponade in the course of treated pneumonia, was referred from the local hospital for emergency surgical intervention. The reason for hospitalization was abdominal pain with nausea; C-reactive protein was in the normal laboratory range (< 5.0 mg/l); no changes in chest X-ray were present. Four days after admission pneumonia of undefined etiology was suspected. The patient underwent antibiotic treatment (amoxicillin + clavulanic acid 3 x 480 mg i.v. for 6 days, netilmicin 3 x 40 mg i.v. for 4 days), and the imaging diagnostics suggested left lung pneumonia with left inferior lobe atelectasis, which impressed the pericardium in a way similar to a left lung tumor with aggressive local growth. The laboratory investigations were not specific for neoplastic disease or tuberculosis infection, although there were atypical forms in the blood shape.
The child was initially referred for chest drainage because of the left pleural effusion (Fig. 1), but the chest drainage did not improve severe hypoxia caused by dyspnea at rest and shortness of breath, despite constant oxygen delivery. After the next 2 days, despite pleural drainage and change of antibiotics (ceftazidime 2 x 500 mg i.v. and fluconazole 1 x 50 mg i.v.), the child deteriorated rapidly due to rapid symptoms of heart failure, shortness of breath and fatigue. In the echocardiography performed just before the intervention there was acute tamponade with local impression of the left atrium and the left ventricle, with functional mitral valve regurgitation grade II (MVI ++), without any congenital defects (Fig. 2). The child was referred for an emergency operation aimed at pericardial tamponade evacuation.
Surgical intervention was performed with the cooperation of a multidisciplinary team (cardiac surgeon, pediatric surgeon, cardiologist, radiologist, oncologist). The chest was opened via a subxiphoid minimally invasive median minithoracotomy incision. After meticulous dissection the pericardial sac was opened and bloody tension fluid was observed. The bloody effusion of 200 ml was evacuated with dynamic outflow under pressure and the heart was dissected free from the fresh fibrous adhesions. In the direct inspection there was clear evidence of solid extrapericardial impression in the area of the left atrium; therefore all manipulation in the pericardium was very gentle. The chest tube with active suction was left in the pericardial sac underneath the inferior wall of the heart. The specimens from pericardial tissue and the fluid were harvested for further laboratory and histopathological tests. The girl was extubated directly in the operative room postoperatively. Postoperative computed tomography did not confirm pericardial infiltration and showed no clear evidence of mediastinal tumor (Fig. 3). The condition of the girl improved and after control echocardiography the drainage was removed 24 hours after surgery. The early postoperative period was uncomplicated. In the postoperative echocardiography there was persistent impression on the left ventricle with pericardial fluid separation inside the pericardium in the field of the left ventricle. Only after the surgery was completed were the previous blood cultures found to be negative. C-reactive protein was 50 mg/l. Pericardial fluid examination revealed bloody liquid with the density of 1.01 g/l (pH 8; protein 53.5 g/l; glucose 62 mg%; LDH 1326 U/I; amylase 36 U/I). Histopathological examination of pericardium and pericardial fluid revealed no signs of neoplastic growth or atypical cells, with inflammatory reaction signs. Viral infection with no symptoms of malignant cells was finally suspected. The child was transferred back to the referring department of pediatrics for continuation of antibiotics on the 4th postoperative day (ceftazidime, fluconazole). Control echocardiography showed no impression over the left ventricle and a small amount of fluid in the area of the left ventricle. The follow-up observation has now reached four years and there have been neither cardiac episodes nor pericardial fluid recurrence.
Thoracic computed tomography image showing pleural fluid with left lung compression.