Abstract
Pericardial effusions, though relatively rare, can lead to life-threatening complications such as cardiac tamponade. While viral etiologies are common culprits, rapid and accurate diagnosis remains challenging. We present the case of a 74-year-old male with a history of upper respiratory infection who developed sudden onset dyspnea and chest discomfort. Bedside point-of-care ultrasound (POCUS) revealed a large pericardial effusion, prompting urgent intervention. Despite initially stable vital signs, the patient rapidly deteriorated, necessitating emergent pericardiocentesis. Laboratory findings and pathology results eventually ruled out common viral causes, guiding diagnosis toward coxsackieviruses A and B, echovirus, adenoviruses, or influenza. This case highlights the critical role of POCUS in resident-led community hospitals, in expediting the diagnosis of pericardial effusions and underscores the need for prompt intervention in cases of cardiac tamponade to prevent adverse outcomes.
Introduction
Pericardial effusion is the accumulation of more than the physiologic amount of fluid around the pericardial sac. Its incidence is estimated to be around 2 cases per 10 000 1 ; compressive syndromes such as cardiac tamponade may occur, characterized by the accumulation of pericardial fluid under pressure.
The diagnosis of cardiac tamponade is clinical, characterized by Beck’s triad of muffled heart sounds, hypotension, and distended neck veins; however, this is present in 48% of the cases.2,3
Electrocardiogram (ECG) and chest x-ray (CXR) lack diagnostic sensitivity, whereas point-of-care ultrasound (POCUS) has been shown to be sensitive, specific, and potentially reduces the time-to-intervention. The definitive diagnosis is provided by 2D echocardiogram, computed tomography scan, although these are not always available in a timely manner and require trained personnel, as is the case in community hospitals, where advanced diagnostic tools and new technologies might not be integrated. Additionally, POCUS is still not part of the ACGME requirements for internal medicine residency, although it is endorsed. We present a case where a patient from a community hospital with unspecific symptoms quickly decompensated; however, real-time diagnosis with POCUS was a key component in decreasing delays to his care and provide life-saving management.
Case Presentation
A 74-year-old male patient with chronic kidney disease stage III, essential hypertension, coronary artery disease with 30% stenosis of the RCA, atrial fibrillation on chronic anticoagulation, rhythm control with amiodarone, rate control with diltiazem, and implantable defibrillator, who had a history of self-resolved upper respiratory infection a week prior to admission, when he started experiencing shortness of breath (SOB).
Shortness of breath was evident during exertion and at rest, presenting with orthopnea and paroxysmal nocturnal dyspnea. His symptoms were accompanied by intermittent chest discomfort and pressure lasting around 15 minutes, worse when laying supine, attenuated by sitting up, non-radiating, and not accompanied by diaphoresis, and self-resolving. He did not take any medications to alleviate discomfort. He mentioned experiencing chills, diaphoresis, nasal congestion, sore throat, arthralgia, unexpected weight loss, and occasional dizziness and imbalance while walking. The day before admission, he could walk his dog for 1 block; on admission day, he could not walk due to persistent SOB. He denied having any fever, cough, hemoptysis, palpitations, edema, muscle, or joint discomfort.
On physical examination his vital signs demonstrated heart rate 74 beats per minute, blood pressure 159/69 mmHg, respiratory rate 20, O2 sat above 94% on room air.
He was in respiratory distress and his cardiovascular assessment revealed distant heart sounds, absence of JVD, abdominal tenderness in the right upper quadrant and epigastric area, as well as malleolar pitting edema. Initial laboratory workup demonstrated the findings described in Table 1.
Initial laboratory results.
Electrocardiogram demonstrated sinus rhythm, 70 bpm, prolonged PR, low voltage in precordial leads, and prolonged QTc.
Findings such as muffled heart sounds, low voltage ECG, and cardiomegaly lead to the decision of performing POCUS at bedside. It demonstrated a large pericardial effusion as visualized in Images 1 and 2.
Chest x-ray demonstrated cardiomegaly, with no evidence of infiltrates or vascular cephalization.
Still figure of POCUS video during apical 4 chamber view. In this image only LV and pericardial fluid are evident.
Another still figure of POCUS video during apical 4 chamber view. In this image only LV and pericardial fluid are evident.
2D-echocardiogram STAT was performed, and cardiology was consulted due to high suspicion of tamponade after POCUS, despite the patient’s adequate vital signs.
He was admitted due to dyspnea secondary to pericardial effusion, ruling out cardiac tamponade and transaminitis of unclear source. A couple of hours after admission, the patient became hemodynamically unstable secondary to cardiogenic shock.
Emergent pericardiocentesis was performed in the ICU by cardiologist with removal of 800 mL of dark purple bloody pericardial fluid. Pericardial window was performed, draining the remaining pericardial effusion (700 mL of bloody, nonclotting fluid); the pericardium and epicardium were extremely inflamed. No isolated source of bleeding; however, some areas of oozing.
Initial 2D-echo demonstrated right atrial invagination and 0.39% inspiratory to expiratory respiratory variation in mitral inflow velocities, consistent with tamponade.
Pathology report of pericardial tissue—benign fibrovascular adipose tissue with reactive fibro-cellular changes, patchy chronic-acute inflammation, and focal fat necrosis. No evidence of malignancy. Tables 2 and 3 demonstrate further laboratory workup, including viral antibodies and pericardial fluid cytology, respectively.
Viral antibodies.
CMV, cytomegalovirus; EBV, Ebstein-Barr virus.
Pericardial fluid cytology.
Discussion
A pericardial effusion is a collection of more than the physiologic amount of fluid (15–50 mL) around the pericardial sac. It can be due to different causes, including viral, uremic, or autoimmune. One of the initial differential diagnoses for our patient was viral pericarditis, as the patient had experienced a recent URI. Labs performed after the pericardiocentesis demonstrated positive antibodies for cytomegalovirus (CMV) IgG and Ebstein-Barr virus (EBV) IgG, ruling it out as the probable cause. However, pathology was unspecific, further guiding diagnosis to viral etiology, which includes coxsackieviruses A and B, echovirus, adenoviruses, or influenza. 4
Pericardial tamponade is the most dangerous complication of pericardial effusions, causing hemodynamic compromise which can be life threatening to the patient. In most cases an identifiable cause is not confirmed, and it is presumed to be viral (80%-90% of cases) or autoimmune etiology. 5 Tamponade occurs in about 33% of cases, idiopathic etiology is 29%, divided into acute and subacute, the latter one being a less dramatic process; patients may be asymptomatic early in the course, but once intrapericardial pressure reaches a critical value, they present with dyspnea, chest discomfort, peripheral edema, and fatigability. In the case of viral etiology, herpesvirus, and human immunodeficiency virus are the most common.5,6 Some herpesvirus such as CMV and EBV can be transmitted by multiple routes: sexual exposure, close contact, tissue exposure, and breastfeeding. The pathophysiological infectious process in immunocompetent hosts is explained by T cells playing a significant role in controlling viral replication and disease but do not eliminate the virus completely. CD4+ and CD8+ T cell responses have been demonstrated in immunocompetent hosts, causing a robust response. 3
Point-of-care ultrasound is a useful tool when time is of the essence and there is a need for quick diagnosis. It has become a key component in the care of critically ill patients. 7 It has also been associated with an earlier intervention in patients with pericardial effusion who end up undergoing drainage during that hospitalization, although with no difference on 28-day mortality associated with POCUS. 8
Studies have shown, nonetheless, that failure to diagnose effusions with any means is associated with increased mortality, dictating the importance of tools like POCUS to diagnose this condition when presentation is not typical. Classic echocardiographic features of tamponade physiology include right atrial systolic collapse, right ventricular diastolic collapse, a paradoxical motion of the interventricular septum, a swinging heart, an enlarged, non-pulsatile inferior vena cava, and a reciprocal variation in ventricular size. 9
Our case is a scenario where a patient was presented with SOB alongside non-specific symptoms that made the diagnosis uncertain. Specific clinical findings such as Beck’s triad (JVD, muffled heart sounds, and hypotension) are clinically seen in around 30% of patients with cardiac tamponade; 10% of these patients will not have any of the clinical findings. 10
A retrospective study in 2 emergency departments included 153 patients with pericardial effusion, demonstrating the limitations of clinical criteria for diagnosis of cardiac tamponade. For JVD, it demonstrated that only 5.9% of patients had JVD, and the sensitivity for this clinical finding was 12.5%. 11 This further confirms that the diagnosis via POCUS can be made even before a patient has clinical signs of tamponade, like in our case. 10 Our patient had muffled heart sounds and ECG with low voltage in precordial leads, as well as CXR that demonstrated cardiomegaly. In the above study for pericardial effusion, only 7.2% had muffled heart sounds with a sensitivity of 37.5%. 11
Point-of-care ultrasound has become increasingly available in many institutions over the past decade, particularly in emergency departments (ED). However, it remains a novel and crucial diagnostic tool, especially in rural areas and community hospitals where advanced diagnostic tools and new technologies might not be integrated. Training programs in rural areas are beginning to incorporate formal POCUS training and certifications into their competencies. It is still not part of the ACGME requirements, although it is highly encouraged during training in different specialties. 12
Point-of-care ultrasound can reduce the need for patient transport between institutions and decrease overall treatment delays. In community hospitals, where consultants may not be available 24/7, and 2D echocardiography results can be delayed for more than 24 to 48 hours, POCUS has proven to be of utmost value. Having residents trained in POCUS and equipped with the necessary resources by the program can optimize the use of medical resources and provide immediate and accurate diagnosis at bedside. It allows for real-time diagnosis and complements physical examination and clinical judgment, particularly when there is a high index of suspicion or specific symptoms such as chest pain and SOB are present.11,13,14
Another novel application of POCUS lies in its ability to easily transfer images via Bluetooth or email, allowing redacted data to be sent directly to consultants’ smartphones. This facilitates timely and informed medical decision-making. Additionally, POCUS enables timely monitoring of disease progression without the constraints of scheduling more complex imaging studies with personnel. For instance, in patients with pericardial effusion, POCUS has an overall accuracy of 98%, with a sensitivity of 96% and specificity of 98%. Cardiac tamponade can be diagnosed with POCUS before the patient shows signs of hypotension or other clinical indicators. 10
Conclusion
Hospitals, regardless of patient inflow, have found in POCUS an essential tool for confirmation of different diagnoses, prompting timely management. In this case, the 2D echo was performed STAT, even after the POCUS assessment; however, the final report was available after 36 hours of pericardiocentesis. Resident intervention through POCUS was the pivotal and timely step that unlocked the diagnosis and life-saving intervention, illustrating its indispensable role in critical situations in community hospitals and delineating the importance of continuous technological innovations.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval
Our institution does not require ethical approval for reporting individual cases or case series.
Informed Consent
Informed consent was not obtained because patient was lost to follow-up.
