Case of the Month

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Case of the Month April, 2015

posted Apr 29, 2015, 4:58 PM by USIG Exec   [ updated Apr 29, 2015, 8:10 PM ]


Pt is a 30 y/o female with a past medical history of AML s/p BM transplant 1 year ago complicated by Graft-vs-Host disease.  Developed shortness of breath suddenly this afternoon, accompanied by lightheadedness and mild left sided chest discomfort.  Previous history of DVT, currently not anticoagulated.  
No fevers, no cough.  No change in her symptoms since onset.


Vitals: Pulse 125, BP 103/80, Temperature 37.1, Resp 17, O2 98%
Gen: NAD, mildly anxious
CV: tachycardic, heart sounds distant, regular rhythm, no m/r/g
PULM: effort normal, CTA-B
Ext: bilateral LE edema, no erythema

Bedside U/S performed for evaluation of right heart strain in the setting of possible pulmonary embolism.

Subxiphoid View


Findings: Pericardial effusion with tamponade physiology

Learning Points:
The heart can be seen moving within the pericardial effusion.  The diastolic collapse of the right ventricle differentiates tamponade physiology from simple pericardial effusion.

Emergency Physicians with a total of 5 hours of training in cardiac ultrasound are able to identify pericardial effusions at the bedside with a sensitivity of 96% and a specificity of 98%.3

Graft-vs-host disease has serosal manifestations in up to 2% of patients.  Rarely, GVHD has been linked to a constrictive pericarditis which can result in pericardial effusion.  These patients have reportedly been responsive to immunosuppressive therapy for GVHD.1

In one study, 1% of patients who underwent hematopoietic stem cell transplantation developed a large pericardial effusion with cardiac tamponade within a year.  The median time frame from transplant to diagnosis was 176 days.  66% of the patients who developed large pericardial effusion with tamponade were found to have graft-vs-host disease.2

Case Resolution:

Because the patient was hemodynamically stable, she did not undergo emergent pericardiocentesis in the Emergency Department.  Instead she was taken to the cath lab for an urgent pericardiocentesis and drain placement.  One week later she underwent cardiac window procedure with biopsy.  Pathology reported “Acute fibrinous and chronic fibrous pericarditis.”  Her hematology/oncology team continues to try and optimize her outpatient GVHD medications.


Ferreira, David C., Jose S. Rodrigues De Oliveira, Katya Parisio, and Fernanda M. Morselli Ramalho. "Pericardial Effusion and Cardiac Tamponade: Clinical Manifestation of Chronic Graft-versus-host Disease After Allogeneic Hematopoietic Stem Cell Transplantation." Revista Brasileira De Hematologia E Hemoterapia 36.2 (2014): 159-161. Web.

Liu, Yao-Chung, Jyh-Pyng Gau, Ying-Chung Hong, Yuan-Bin Yu, Liang-Tsai Hsiao, Jin-Hwang Liu, Tzeon-Jye Chiou, Po-Min Chen, and Cheng-Hwai Tzeng. "Large Pericardial Effusion as a Life-threatening Complication After Hematopoietic Stem Cell Transplantation—association with Chronic GVHD in Late-onset Adult Patients." Annals of Hematology 91.91 (2012): 1953-1958. Web.

Mandavia, Diku P., Richard J. Hoffner, Kevin Mahaney, and Sean O. Henderson. "Bedside Echocardiography by Emergency Physicians." Annals of Emergency Medicine 38.4 (2001): 377-382. Web.

Case of the Month - November 2014

posted Nov 10, 2014, 5:56 PM by Kelsey Murray   [ updated Nov 10, 2014, 5:56 PM by Stephen Gardner ]

19 y female with 10 hours of abdominal pain. Pain has now migrated to RLQ.

Patient reports nausea and vomiting. No fevers.

No trauma.

No dysuria or hematuria.

RLQ US using linear probe at 4.3 cm depth shows blind ending pouch draped over iliac artery

Appendix is non compressible, has no flow, has no peristalsis, and when normal measures 6mm or less.

RUQ US using curvinlinear probe at 13 cm depth shows anechoic region in pelvis. When color placed on this region there is no flow. This is suggestive of hydronephrosis.

Patient ended up having right renal stone as cause of pain.


  •          Found normal appendix
  •          Found GU pathology

See article in NEJM in regards to US v CT for renal Colic

Check back in December for next month's case!

Coming Soon!

posted Nov 8, 2014, 2:06 PM by Kelsey Murray   [ updated Nov 8, 2014, 2:06 PM by Stephen Gardner ]

Check back soon for more cases of the month. 
In the meantime, you can access our archived cases here: Archives

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