The patient was a 62-year-old African American male, with a past medical history of HIV, latent TB, chronic kidney disease stage 3a, essential hypertension, hyperlipidemia, and type 2 diabetes mellitus, who was brought to the emergency department by ambulance with complaints of a one-day history of chest pain, body aches, and shortness of breath. His symptoms worsened with a cough and had no apparent alleviating factors. On arrival, his vital signs showed a temperature of 101.1  F and a heart rate of 129 beats per minute. His blood pressure was 132/65 mmHg, and his respiratory rate was 19, with an oxygen saturation of 95% on room air. He did not show any signs of acute distress on physical examination. A cardiac examination demonstrated tachycardia. He had been on elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide (Genvoya) for HIV. He had not been aware of his CD4 count before arrival. He had no previous reported history of opportunistic infection. He conveyed that he had completed treatment for his latent TB in the distant past. On arrival, EKG showed ST elevation in multiple leads (Figure 1), but his troponin was within normal limits. Other initial parameters were as follows - WBC: 7.4 x 109/L, hemoglobin: 11.0 g/dL, platelet count: 266 103/microl, erythrocyte sedimentation rate (ESR): 70 mm/hr, C-reactive protein (CRP): 9 mg/dL, and lactic acid: 0.70 mmol/L. As for imaging studies, cardiomegaly was present on his chest X-ray (Figure 2), and an echocardiogram showed a moderate to large pericardial effusion. A previous echocardiogram about 18 months ago had been within the normal range. The patient was hemodynamically stable with no signs of cardiac tamponade, but a pericardiocentesis was deemed necessary due to the volume of fluid observed on the echocardiogram.
Approximately 700 mL of serosanguinous fluid was extracted through a subxiphoid pericardiocentesis the next day after his presentation. The pericardial fluid analysis was indefinite, showing only blood and proteinaceous debris and rare, intact, and benign-appearing mesothelial cells. No atypical cytologic features were seen. The acid-fast smear for Mycobacterium was negative. Further serum testing showed that his antinuclear antibody was in the normal range and his CD4 count was 265 cells/mm3. A Karius test was performed and revealed the presence of Epstein-Barr virus (EBV). However, an antibody panel later demonstrated that this was not an acute EBV infection. The patient received empiric antibiotics and continued improving symptomatically, but the definitive cause of the effusion remained undetermined. Since this was a large effusion without a sign of tamponade, it was likely a subacute or chronic effusion with acute viral or idiopathic pericarditis. Medication-induced pericardial effusion has been described, specifically with isoniazid. Our patient reported undergoing treatment for latent TB in the remote past, and hence this was an unlikely cause.