Case presentation
A 84 year old female patients with a medical history of hypertension, atrial fibrillation, asthma, hyperlipidemia, left breast cancer in remission for 2 years after lumpectomy and chemotherapy and a recent history of SARS-CoV-2 bilateral pneumoniae discharged with supplementary oxygen two weeks previously, presented to the emergency room with worsening dyspnea since discharged and lower extremity edemas. Her presenting blood pressure (BP) was 125/85 mmHg, heart rate (HR) was 147 beats/minute, respiratory rate (RR) was 20 breaths/minute, temperature was 96.2 ºF and she was saturating 83% on room air rising with nasal cannulas at 2 liters to 97%. Physical exam showed a pathological pulmonary auscultation with bilateral crackles and confirmed edemas in legs, and absence of jugular engorgement. An electrocardiogram at presentation showed atrial fibrillation with diffusely decreased voltages (Figure 1). The patient’s chest x-ray at presentation showed bilateral pleural effusion predominantly at the left side and a cardiomegaly not described in previous images (Figure 2). Blood test at presentation showed and hemogram with leukocytosis and neutrophilia, blood chemistry showed a normal renal function and increased inflammatory markers, cardiac enzymes showed negative troponins with minimal elevated brain natriuretic peptide and arterial blood gas confirmed a partial respiratory insufficiency. With a first diagnostic approach of heart failure the patient was admitted, and diuretics were started.
On day 2 of hospitalization, point-of-care ultrasound (POCUS) was performed, confirmed with a transthoracic echocardiography (TTE), showing a severe circumferential pericardial effusion. Partial collapse of right atrium, respirophasic variation of tricuspid flow < 50% and dilatation of inferior vena cava with inspiratory collapse (Figure 3).
Since this time, the patient was hemodynamically stable with BP pressure of 126/82 mmHg and a HR of 96 beats/minute. In the management of severe pericardial effusion in a stable patient, it is decided to initiate medical treatment and continue with the diagnostic approach. Diuretics were withdrawn, non-steroidal anti-inflammatories (NSAIDs) were started with ibuprofen on a dose of 600 mg every 8 hours. With the history of recent breast cancer, a thoracentesis, a body scan, and tumor markers were requested. The thoracocentesis showed a transudative fluid (Table 1) and the body scan was negative for malignancy.
The patient continued with NSAIDS till day 5 of hospitalization when the dyspnea increased accompanied by a BP of 100/60 mmHg, a HR of 105 beats/min and on blood exams an acute kidney injury AKIN I was detected. In consequence of this finding, a new TTE was repeated showing a collapse of the right atrium and ventricle with non-inspiratory collapse of the inferior vena cava. The patient was immediately transferred to the intensive cardiology unit for pericardiocentesis. After extraction of 1 liter of pericardial fluid with serous appearance (Table 1), the patient presented an improvement of her dyspnea, blood pressure, heart rate stabilized and normalized kidney function (figure 4). Pericardial fluid was analyzed showing an exudative fluid with negative bacterial, mycobacterial, and fungal cultures. PCR for COVID-19 in pericardial fluid is not available in our center but since the past infection the pericardial effusion was attributed to a past pericarditis secondary to COVID-19.