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 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