Differential Diagnosis, Investigations and Treatment

The differential diagnoses considered at presentation were cardiac tamponade, acute coronary syndrome and hyperkalemia.
Electrocardiography revealed a prolonged PR interval with tall T waves. The serum potassium was 6.6 mmol/L and serum creatinine was 10.2 mg/dL. Cardiac enzymes were not elevated and transthoracic echocardiography revealed moderate pericardial effusion, not in tamponade, with dilated inferior venacava, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, grade II left ventricular systolic dysfunction with no clots or vegetations (Figure 1). D-dimer was elevated to 5 mcg/ml from a baseline of 0.9 mcg/ml.
She underwent emergency hemodialysis through a right internal jugular vein hemodialysis catheter for refractory hyperkalemia, associated with arrhythmia and hemodynamic instability. Her condition gradually improved over the next 48 hours with a return to sinus rhythm with blood pressure of 130/70 mm of Hg.
Two days later vascular surgeons attempted to salvage the AVF by manual manipulation. Under local anesthesia, milking was attempted to salvage the fistula through a venous incision. A thrombus 0.5 X 0.5 cm was removed. Although a thrill was appreciated after the procedure, she acutely developed shortness of breath with a continuous cough followed by gradual drop in SpO2. Oxygen requirements increased from nasal prongs to Venturi mask with FiO2 0.6. She became drowsy and was intubated in view of her worsening respiratory distress and shifted to the intensive care unit (ICU). She had sinus tachycardia of 130/m, BP was 90/60 mm of Hg with support of noradrenaline, SpO2 was 89% with FiO2 70%.
An acute coronary event and pulmonary embolism were the diagnoses contemplated. Electrocardiography showed sinus tachycardia. Echocardiography showed no regional wall abnormalities and there was no tamponade. Troponin I was elevated. A CT-pulmonary angiography was done. Findings included completely occluding thrombosis in ascending, descending branches of right and descending branch of left pulmonary artery with moderate pericardial effusion and dilated inferior venacava and hepatic veins (Figure 2 Plate A and Figure 2 Plate B).
Treatment was initiated with 60 mg of Enoxaparin Q24h, in view of her CKD. Over the next few hours, her vasopressor requirement gradually came down, repeat echocardiography did now show any cardiac dysfunction except for the effusion and it was concluded there was no need for thrombolytic therapy.