A 40-year-old Ghanaian female farmer presented to her internist with an exacerbation of asthma. She has lived all of her life in Tamale, Ghana, and she and her physician were accustomed to asthmatics having increased symptoms at this time, during the dry season when the Harmattan, dry desert winds carrying sand off of the Sahara, blanket northern Ghana. Her baseline medication was only an albuterol inhaler, which was used rarely on an as-needed basis. In prior years, she would increase her albuterol to two puffs four times a day, and that would typically control her bronchospasm. For the previous 5 weeks, her medications were albuterol inhaler two puffs four times a day, budesonide 400 mug two puffs two times a day, montelukast 10 mg per day, and fluticasone 250 mug/salmeterol 50 mug one puff two times a day. Her respiratory symptoms did not abate, so she was put on two courses of prednisone 20 mg per day for 5 days, the last course ending 2 weeks previously, without relief.
She presented to an outpatient medical clinic in Tamale, a city with limited access to x-rays or blood tests. The patient complained of mild shortness of breath at rest but severe dyspnea on exertion for 1 month that had increased over the past 2 weeks despite the additional medications ordered by her internist. She denied experiencing orthopnea, chest pain, cough, fever, chills, abdominal pain, heartburn, dyspepsia, leg trauma, or swelling. The symptoms did not alter at any time of the day. She had a history of hypertension diagnosed many years ago but never took antihypertensive medication due to financial constraints. She also has had many episodes of malaria, with the last episode 5 months earlier, which was treated with artemether/lumefantrine. Her family history is significant for a mother who has had asthma since she was a teenager. The patient is poor, lives in Tamale, has never had a chest x-ray, and has had no blood tests for 15 years. Controlling her asthma is crucial as she is a farmer who works in the field 7 days a week performing manual labor.
The patient is a thin, muscular woman who appeared with mild dyspnea at rest. She was able to speak in full sentences without distress but had a mild increase in shortness of breath when asked to climb onto the exam table. She had a blood pressure of 106/70, heart rate of 98, respiratory rate of 22, and temperature of 37  C (98.6  F). Examination of the nose and throat were normal. Auscultation of the lungs was remarkable for bilateral wheezing in mid-late expiration in all lung fields with prolonged expiration and 1+ bibasilar inspiratory crackles. There were no areas of dullness to percussion. Cardiac exam revealed a regular rate and rhythm without murmurs, and heart sounds were not muffled. Neck veins were unable to be visualized. Abdominal exam revealed a scaphoid abdomen with normal bowel sounds, no masses or organomegaly, and no tenderness. There was no calf tenderness and no lower-extremity edema. She had 2+ carotid, dorsalis pedis, femoral, and radial pulses bilaterally.
The clinic did not have radiographic capabilities. However, a physician from the United States was visiting and teaching ultrasonography to the Ghanaian clinicians. He used a portable bedside ultrasound that had been previously donated to evaluate the patient. Subcostal and 4-chamber apical views revealed a swinging heart within a large pericardial effusion with diastolic collapse of the right ventricle. A diagnosis of pericardial tamponade was made, and an emergency pericardiocentesis was performed via a parasternal approach in the left third intercostal space. After 100 cc of straw-colored fluid were removed, the patient was significantly improved. A total of 750 cc was aspirated, and a repeat ultrasound now revealed a trivial effusion with normal ventricular function. The patient then stated that her breathing was normal. Post-procedure, the patient had clear lungs, a blood pressure of 180/100, a heart rate of 72, and a respiratory rate of 12. She was referred to Accra, the capital of Ghana, for blood tests that were performed 10 days later. Her creatinine was 8.2 and blood urea nitrogen (BUN) was 92. She had a normal chest x-ray and after an extensive evaluation by a nephrology consultant was diagnosed with renal failure due to hypertensive nephropathy. She received dialysis and 1 year later had no recurrence of cardiac tamponade but still required albuterol inhaler as needed that was increased to every 6 hours during the Harmattan to control her bronchospasm.