Article, Oncology

Cardiac tamponade as unusual presentation of underlying unrecognized cancer

Case Report

Cardiac tamponade as Unusual presentation of underlying unrecognized cancerB

Malignant pericardial effusion is a common complication of advanced cancers. Presentation may be mild and subtle, but patients may also experience cardiac tamponade, a real medical emergency caused by fluid accumulation around the cardiac chambers. Although infrequently, symptomatic pericardial effusion with Hemodynamic compromise can be the initial presentation of underlying malignancies. Recent medical literature reported cases of cardiac tampo- nade as the first presentation sign of several organs. We report here 2 Clinical cases characterized by cardiac tamponade as the presentation of unrecognized underlying malignancies, for example, urinary bladder and early lymph node metastasis (detectable with immunoreactivity only) of non-small-cell Lung cancer. Patients presenting with cardiac tamponade, after hemodynamic stabilization and exclusion of more frequent causes, should deserve a search for underlying unrecognized neoplastic disease.

Cardiac tamponade is a real medical emergency caused by fluid accumulation around the cardiac chambers that influence cardiac output [1].

Case 1. A 54-year-old apparently healthy man presented with unexplained shortness of breath. Vital signs were as follows: blood pressure, 120/70 mm Hg; pulse, 100 beats/ min; respiration, 26 breaths/min; and pulse oximetry, 96% on room air. The physical examination results were unremarkable. Laboratory data showed hemoglobin 11.4 g/dL, white blood cell count 8900 (77% neutrophils), erythrocyte sedimentation rate 52 mm/h, and C-reactive protein 7.14 mg/dL. Echocardiographic examination revealed the presence of pericardial effusion, with hemody- namic compromise and initial cardiac tamponade. Five hundred milliliters of hematic fluid was evacuated from the pericardium. Computed tomography scan showed several mediastinal lymph nodes, with clear lungs. The patient underwent thoracoscopic mediastinotomy with pericardial fenestration and video-assisted mediastinal lymph node biopsy. Histology plus thyroid transcription factor 1 immunoreactivity allowed diagnosis of metastasis from

B This study was supported, in part, by a scientific grant

bFinanziamento per ricerca localeQ from the University of Ferrara, Italy.

non-small-cell lung cancer. After 2 cycles of systemic chemotherapy (cisplatinum plus gemcitabine), the patient suddenly died from cerebral hemorrhage 3 months later.

Case 2. A 60-year-old man, who had been followed up for 5 years after being surgically treated for urinary bladder neoplasm, presented with a scrotal swelling. Vital signs were as follows: blood pressure, 110/70 mm Hg; pulse, 96 beats/min; respiration, 18 breaths/min; and pulse oximetry, 98% on room air. Genital examination showed penile and scrotal edema, normal testes, and nontender inguinal lymph nodes. The remaining physical examination results were unremarkable. Laboratory data showed hemoglobin 12.3 g/ dL, white blood cell count 7500 (70% neutrophils), erythrocyte sedimentation rate 42 mm/h, and C-reactive protein 4.32 mg/dL. Computed tomography scan showed multiple mediastinal and inguinal lymph nodes. Suddenly, the condition of the patient rapidly deteriorated, with onset of severe acute dyspnea and shock. Echocardiography demonstrated large amount of pericardial effusion with diastolic right ventricle compression. The clinical echocar- diography features were consistent of cardiac tamponade. One thousand milliliters of hematic fluid was evacuated from the pericardium, and thoracoscopic pericardial fenes- tration was performed. Inguinal lymph node biopsy showed metastasis of poorly differentiated adenocarcinoma, proba- bly originating from the urinary bladder. The patient, treated with systemic chemotherapy (carboplatinum plus gemcita- bine), is still in good health condition after 12 months.

Malignant pericardial effusion is a common complication of advanced cancers. Presentation may be mild and subtle, but patients may also experience cardiac tamponade [2]. Sometimes, however, symptomatic pericardial effusion with hemodynamic compromise can be the initial presentation of an unrecognized underlying malignancy. A 9-year retro- spective study [3] on a cohort of patients who underwent pericardiocentesis showed that symptomatic pericardial effusion was the presentation of an unrecognized underlying malignancy in approximately one fifth of the patients with a nonrevealing basic workup. However, infrequent cardiac tamponade can be the first presentation of an underlying unrecognized cancer. Recent medical literature reported cases of cardiac tamponade as the first presentation sign of thymus, thyroid, larynx, and esophagus cancer [4-7]. Our cases add to this list also urinary bladder and early lymph node metastasis (detectable with immunoreactivity only) of

0735-6757/$ – see front matter D 2007

737.e6 Case Report

non-small-cell lung cancer. Thus, patients presenting with cardiac tamponade, after stabilization by means of fluid resuscitation and removal of pericardial effusion and exclusion of more frequent causes, should deserve a prompt search for underlying unrecognized neoplastic disease.

Pierluigi Ballardini MD Guido Margutti MD Arnaldo Zangirolami MD Marilena Tampieri MD Elena Incasa MD Susanna Gamberini MD

Department of Internal Medicine, Hospital of the Delta Lagosanto (FE), Azienda USL di Ferrara, Italy

Roberto Manfredini MD Department of Internal Medicine Hospital of the Delta, Lagosanto (FE) Azienda USL di Ferrara, Italy

Department of Clinical and Experimental Medicine Section of Clinica Medica and Vascular Diseases Center

University of Ferrara, Italy E-mail addresses: [email protected], [email protected]

doi:10.1016/j.ajem.2007.01.011

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