April 2022 Medical Image of the Month: COVID Pericarditis

Figure 1. A: Pericardial enhancement on thoracic CT (red arrows). B: Thoracic CT in lung windows showing mosaic attenuation (black arrows) and bilateral pleural effusions (red arrows).

Figure 2. A: Static image of parasternal short axis on transthoracic echocardiogram showing moderate, generalized pericardial effusion with right ventricular diastolic collapse (red arrow). B. Static image of parasternal long axis on transthoracic echocardiogram again showing a moderate, generalized pericardial effusion (red arrow). Lower panel: video of echocardiogram in parasternal long axis view.

A 76-year-old patient presented with fatigue and shortness of breath after missing one session of dialysis. Past medical history included end stage renal disease on hemodialysis and atrial fibrillation on anticoagulation. Initial labs showed that she was COVID positive with mild elevation in troponin and a BNP 1200. While an inpatient, she had received a few sessions of dialysis and treatment for COVID (including dexamethasone and remdesivir). Initial echo showed an ejection fraction of 60-65% with a small generalized pericardial effusion, a thickened pericardium with calcification. A few days after admission patient was suddenly noted to be hypotensive with systolic blood pressure in the 70s and altered mental status. Repeated labs showed a D-Dimer of 17,232, leukocytosis, lactic acidosis, troponin 0.556 ng/ml and arterial blood gas with metabolic acidosis. With a worsening clinical picture, repeat imaging was obtained. CT angiography of the chest was negative for pulmonary embolism; however, it showed a large pericardial effusion with reduced size of the right ventricle more so than left, concerning for cardiac tamponade (Figure 1A). CT chest also showed moderate-to-large pleural effusions with scattered mosaic attenuation of the lung parenchyma (Figure 1B). Repeat transthoracic echocardiogram had a moderate generalized pericardial effusion with right ventricular diastolic collapse concerning for pericardial tamponade (Figure 2). Her airway was secured with endotracheal intubation and vasopressors added for hemodynamic support. Pericardiocentesis was indicated however, patient’s INR was severely elevated in the setting of anticoagulation use. Efforts were made to lower INR with FFP; however, patient had a PEA arrest the following day and expired.

COVID-19 has been classically known for its detrimental lung damage; however, it has shown to cause extrapulmonary effects as well. Cardiac injury is one phenomenon that has been seen with the fulminant inflammatory state that COVID is known to cause. With a few cases reported for COVID pericarditis, it is a possible culprit when all other causes have been ruled out. Pericardial involvement can be seen in about 20% of COVID 19 cases, with effusion found in about 5% of patients (1). Concomitant myocarditis can also be found in up to 17% of patients. Having isolated cardiac involvement with COVID is rare, with most cases presenting mainly as lung involvement in addition to other organs affected as well. Clinically, patients with pericarditis typically experience chest pain and in the setting of COVID infection, an increase in inflammatory markers. Characteristic findings of pericarditis include friction rub on auscultation, diffuse ST elevations on EKG and a potential progression to pericardial effusion on echo. When a pericardial effusion becomes large enough, it can progress to cardiac tamponade (2). Having a high clinical suspicion for tamponade is crucial in a patient who has developed respiratory distress and hypotension in the setting of recent viral pericarditis. It is a clinical diagnosis and requires rapid treatment with pericardiocentesis to prevent cardiac arrest.

Sarah Youkhana, MD¹ and Maged Tanios, MD²

St. Mary Medical Center, Long Beach, CA USA

¹Internal Medicine Resident, PGY-3

²Medical Director, Critical Care Services

References

1. Diaz-Arocutipa C, Saucedo-Chinchay J, Imazio M. Pericarditis in patients with COVID-19: a systematic review. J Cardiovasc Med (Hagerstown). 2021 Sep 1;22(9):693-700. [CrossRef] [PubMed]
2. Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA. 2015 Oct 13;314(14):1498-506. [CrossRef] [PubMed]

Cite as: Youkhana S, Tanios M. April 2022 Medical Image of the Month: COVID Pericarditis. Southwest J Pulm Crit Care Sleep 2022;24(4):62-3. doi: https://doi.org/10.13175/swjpccs006-22 PDF

Medical Image of the Month: Malignant Pleural and Pericardial Effusions

Figure 1. CTA chest axial view showing moderate pericardial effusion, bilateral pleural effusions and an anterior mediastinal mass.

Figure 2. Echocardiography subcostal four-chambered view showing a large pericardial effusion with right ventricular collapse during diastole.

A 67-year-old woman with a history of presumed thymoma presented to the emergency department with four weeks of progressive shortness of breath and wheezing. CT imaging of the chest on arrival demonstrated a 13.1 x 8.6 x 8.2 cm anterior mediastinal mass with compression of the SVC, pulmonary veins, and right pulmonary artery (Figure 1). A moderate pericardial effusion was also seen. A transthoracic echocardiogram was performed to further evaluate the pericardial effusion, which revealed diastolic collapse of the right ventricle consistent with cardiac tamponade (Figure 2). The patient was taken for urgent pericardiocentesis, which drained 450cc of sanguineous fluid. Percutaneous biopsy of the mass revealed poorly differentiated carcinoma suspicious for a primary breast malignancy. Cytology of the pericardial fluid did not demonstrate malignancy, however. Cytology of subsequent pleural effusion also was not positive for malignancy, although, both effusions are believed to be related to the malignancy even if no malignant cells were present on analysis.

Malignant pericardial effusions account for 18-23% of cases, and are one of the most common causes of hemorrhagic effusions. Multiple types of cancers can involve the pericardium; lung cancer is the most common but lymphoma, leukemia, melanoma, and breast cancer are other potentially causative malignancies. Presence of a symptomatic malignant effusion is a poor prognostic indicator with median survival on the order of 2-4 months after diagnosis, although certain malignancies (e.g. hematologic rather than solid) may have better results (1).

Nathan Coffman MD and Jessica Vondrak MD

Department of Internal Medicine

Banner University Medical Center

University of Arizona

Tucson, AZ USA

Reference

1. Dequanter D, Lothaire P, Berghmans T, Sculier JP. Severe pericardial effusion in patients with concurrent malignancy: a retrospective analysis of prognostic factors influencing survival. Ann Surg Oncol. 2008 Nov;15(11):3268-71. [CrossRef] [PubMed] 

Cite as: Coffman N, Vondrak J. Medical image of the month: Malignant pleural and pericardial effusions. Southwest J Pulm Crit Care. 2018;17(5): . doi: https://doi.org/10.13175/swjpcc107-18 PDF 

Medical Image of the Week: Pericardial Effusion in a Setting of Bacterial Endocarditis

Figure 1. Single portable semi-upright chest radiograph with findings of an enlarged cardiomediastinal silhouette, and indistinctness of the perihilar vasculature.

Figure 2. Axial contrast enhanced computed tomography—soft tissue windows. A large concentric rim (fluid density) surrounds all four chambers of the heart, consistent with a pericardial effusion. Notice how the right ventricle is normal, which can be collapsed in cardiac tamponade.

A 25-year-old man with an extensive history of intravenous drug abuse presents to the hospital with worsening shortness of breath and fevers for two weeks. In the emergency department, he was initially provided breathing treatments including ipratropium/albuterol and methylprednisolone. As the patient still required supplemental oxygen, a chest radiograph was performed to evaluate for an underlying infectious etiology.

However, the chest radiograph portrayed an enlarged cardiomediastinal silhouette in a “water-bottle” appearance and obscuration of the hilar vessels (Figure 1). Given these findings, there was a high concern for a pericardial effusion, and the physicians opted for further cross-sectional imaging. The contrast enhanced computed tomography (CT) images confirmed the aforementioned diagnosis (Figure 2). As blood cultures eventually grew Staphylococcus aureus, and given the patient’s extensive history of intravenous drug abuse, there was a high suspicion for bacterial endocarditis. A subsequent echocardiogram verified several valvular vegetations in keeping with endocarditis. The patient’s vitals remained stable throughout the hospital course, and he was continued on long-term antibiotic therapy.

Chest radiographs are often unreliable in depicting pericardial effusions, as they require at least 200 mL of pericardial fluid to portray an enlarged cardiomediastinal silhouette (1).  As fluid continues to accumulate in the pericardial space, the increase in pericardial pressure on the chambers can eventually lead to cardiac tamponade—a form of cardiogenic shock (2). Cardiac tamponade will result in a decrease in stroke volume, decreased blood pressure, and ultimately a diminished cardiac output; all of which require immediate intervention (2). Echocardiography remains the imaging modality of choice given its portability and high sensitivity in diagnosing pericardial fluid (3).

Amrit Hansra, MD

Department of Medical Imaging

University of Arizona

Tucson, AZ

References

1. Restrepo CS, Lemos DF, Lemos JA, et al. Imaging findings in cardiac tamponade with emphasis on CT. Radiographics. 2007 Nov-Dec;27(6):1595-610. [CrossRef] [PubMed]
2. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003 Aug 14;349(7):684-90. [CrossRef] [PubMed]
3. Chong HH, Plotnick GD. Pericardial effusion and tamponade: evaluation, imaging modalities, and management. Compr Ther. 1995 Jul;21(7):378-85. [PubMed] 

Cite as: Hansra A. Medical image of the week: pericardial effusion in a setting of bacterial endocarditis. Southwest J Pulm Crit Care. 2016 Mar;12(3):110-1. doi: http://dx.doi.org/10.13175/swjpcc009-16 PDF

Medical Image of the Week: Necrotizing Pancreatitis

Figure 1. Contrast-enhanced CT of the abdomen and pelvis demonstrates innumerable foci of gas adjacent to the pancreatic head/body junction (red arrow) with marked inflammation of the pancreatic head (blue arrow). These findings are consistent with necrotizing pancreatitis.

A 60-year-old man with a past medical history significant for coronary artery disease status post percutaneous coronary intervention was admitted to Banner University Medical Center for acute pancreatitis complicated by a pericardial effusion requiring pericardiocentesis. The following day, the patient developed severe shortness of breath requiring increasing amounts of supplemental oxygen. The patient was emergently transferred to ICU for noninvasive bilevel positive airway pressure ventilation, but he subsequently required intubation. Throughout his worsening condition, he denied any abdominal pain, only relaying ongoing substernal chest pain. His troponins, however, remained negative and echocardiography failed to show any reaccumulation of the pericardial effusion.

CT scan of the chest failed to show any pulmonary embolism. But, CT abdomen displayed acute pancreatitis complicated by peripancreatic gas consistent with necrotizing pancreatitis (Figure 1). Emergent laparotomy was completed. There were no signs of stomach or duodenal perforation. Purulent fluid was removed from the lesser sac and an irrigating stump was placed.

Hem Desai MD¹, Tammer Elani MD¹, Nour Alhoda Parsa MD¹ and Kareem Ahmad MD²

¹Department of Internal Medicine and ²Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona

Tucson, AZ

Reference

1. Thoeni RF. The revised Atlanta classification of acute pancreatitis: Its importance for the radiologist and its effect on treatment. Radiology. 2012;262(3):751-64. [CrossRef] [PubMed]

Reference as: Desai H, Elani T, Parsa NA, Ahmad K. Medical image of the week: necrotizing pancreatitis. Southwest J Pulm Crit Care. 2015;11(2):84-5. doi: http://dx.doi.org/10.13175/swjpcc080-15 PDF

February 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 37-year-old man, a former smoker (quit 10 years ago) presented to his physician as an outpatient with complaints of intermittent chest pain, malaise, and intermittent fever. Stress ECG and upper endoscopy were negative. His previous medical history was otherwise unremarkable. Various physicians told the patient his symptoms were due to “stress”; presumptive antibiotic treatment had no effect.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of five panels)

1. The chest radiograph shows a circumscribed pulmonary mass
2. The chest radiograph shows asymmetric pulmonary vascularity
3. The chest radiograph shows bilateral linear and reticular opacities and diminished lung volumes suggesting fibrotic lung disease
4. The chest radiograph shows cardiomegaly and small pleural effusions
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB. February 2015 imaging case of the month. Soutwest J Pulm Crit Care. 2015:10(2):70-6. doi: http://dx.doi.org/10.13175/swjpcc018-15 PDF

Medical Image of the Week: Malignant Pericardial Effusion and Cardiac Tamponade

Figure 1. EKG showing sinus tachycardia, low QRS voltage and electric alternans, suggesting pericardial effusion.

Figure 2. Chest X-ray pre- and post-pericardiocentesis. Panel A: Cardiomegaly with water bottle shape shown before procedure. Panel B: resolution after drainage of 1.8 L of pericardial fluid.

Figure 3. Echocardiogram showing massive pericardial effusion (dashed line), floating heart, and collapsed right atrium and ventricle that are consistent with cardiac tamponade.

Figure 4. Intra-pericardial space pressure tracing with maximum pressure measured at 25 mmHg.

A 53 year old woman with history of metastatic breast cancer presented to the emergency department (ED) with worsening shortness of breath for 2 weeks. She was initially diagnosed with grade III breast intraductal carcinoma was estrogen receptor, progesterone receptor, and HER2 negative 5 years earlier. A lumpectomy was performed followed by 4 cycles of chemotherapy with cyclophosphamide and taxol as well as radiation therapy. However, follow-up CT and MRI and subsequent biopsy demonstrated metastatic disease in the left adrenal gland, right ovary, and mediastinal lymph nodes, for which additional chemotherapy was started a month prior to presentation. In the ED, the patient was tachycardic and tachypneic. Vital signs showed BP 112/94 mmHg, HR 118 /min, RR 28 /min, temperature 97.5 °F, and SpO₂ 97 % with room air. EKG showed sinus tachycardia, low QRS voltage with electric alternans (Figure 1), and chest x-ray demonstrated cardiomegaly with a water bottle shaped heart (Figure 2A), suggesting pericardial effusion. Over the hour at ED, patient developed sudden hypotension with BP of 78/44. 1 L of normal saline was administrated immediately, and patient was transferred to cardiac catherization laboratory for emergent pericardiocentesis. Echocardiogram before the procedure demonstrated massive pericardial effusion and a floating heart in the pericardial space (Figure 3). Intra-pericardial pressure was measured at 25 mmHg (Figure 4). A total of 1.8 L of sanguineous fluid was drained. Pericardial fluid cell count with differential and chemistry showed WBC 2444 /μL, RBC 1480000 /μL, lymphocytes 32 /μL , neutrophils 64 /μL, glucose 108 mg/dL, and protein 5.2 g/dL, and cytology analysis with fluid demonstrated adenocarcinoma, confirming the diagnosis of malignant pericardial effusion and cardiac tamponade. Chest x-ray after the procedure showing resolution of the water bottle-shaped heart (Figure 2B). Elective thoracotomy with pericardiectomy was performed the next day, and patient was eventually discharged in stable condition.

Pericardial effusion seen in cancer patients may results from several sources. Constrictive pericarditis with pericardial effusion can arise as a complication of radiation therapy. Uremia and certain medications can induce pericardial effusion as well. Metastatic cardiac involvement may causes pericardial effusion. A previous autopsy study showed 10.7 % of patients with underlying malignancy had metastatic disease in the heart (1). Adenocarcinoma is the most frequently found cell type, and lung cancer, malignant lymphoma and breast cancers are the most common primary tumors metastasizing to the heart. Symptoms of malignant pericardial effusion include shortness of breath, cough, chest pain, and edema. Vaitkus et al. (2) proposed three goals in the management of symptomatic malignant pericardial effusion:1) relief of immediate symptoms, 2) determination of cause, and 3) prevention of recurrence (2). No single modality has been proved to be superior since most patients with malignant pericardial effusion need more than one therapeutic modality. Pericardiocentesis is commonly used for acute symptomatic relief while other chemical or mechanical modalities such as systemic chemotherapy, radiation therapy, intrapericardial sclerosing agents, indwelling pericardial catheter, or thoracotomy with pericardiectomy are options to prevent relapse.

Seongseok Yun, MD PhD; Juhyung Sun, BS; Rorak Hooten, MD; Yasir Khan, MD;Craig Jenkins, MD

Department of Medicine, University of Arizona, Tucson, AZ 85724, USA

References

1. Klatt EC, Heitz DR. Cardiac metastases. Cancer. 1990;65(6):1456-9. [CrossRef]
2. Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial effusion. JAMA. 1994;272(1):59-64. [CrossRef] [PubMed] 

Reference as: Yun S, Sun J, Hooten R, Khan Y, Jenkins C. Medical image of the week: malignant pericardial effusion and cardiac tamponade. Southwest J Pulm Crit Care. 2014;8(6):343-6. doi: http://dx.doi.org/10.13175/swjpcc048-14 PDF