Case of the Month April, 2015

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

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.

PE:

Vitals: Pulse 125, BP 103/80, Temperature 37.1, Resp 17, O2 98%
Gen: NAD, mildly anxious
HEENT: No JVD
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





PSLA 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.





Sources:

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.

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