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were withdrawn, non-steroidal anti-inflammatories (NSAIDs) were started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.