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