Lung Cancer: Student/Resident Case Report Poster - Lung Cancer II |

A Rare Case of Pericardial Tamponade as the Initial Presentation of Metastatic Non-small Cell Lung Cancer FREE TO VIEW

Adnan Khalif, MD; Debjit Saha, MD; Brad Butcher, MD; Dr. Bryan Robertson, MD
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Department of Internal Medicine, University of Pittsburgh Medical Center, Mercy, Pittsburgh, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):761A. doi:10.1016/j.chest.2016.08.856
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SESSION TITLE: Student/Resident Case Report Poster - Lung Cancer II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Neoplastic involvement of the pericardium is an uncommon presentation of a primary lung malignancy. Lung cancer is the second most common malignancy, and 20% of patients present with localized disease. We present a case of metastatic lung adenocarcinoma initially manifesting as a hemorrhagic pericardial effusion complicated by pericardial tamponade.

CASE PRESENTATION: A 52-year-old male smoker from Vietnam presented to our hospital with progressive dyspnea and cough. On admission, he was tachycardic to 112 beats/minute, tachypneic to 28 breaths/minute, and hypoxemic, with an oxygen saturation of 91% on 4L of oxygen. CT angiogram of the chest demonstrated a pleural effusion occupying the entire left hemithorax, a moderate pericardial effusion, and a subsegmental pulmonary embolism. EKG revealed low QRS voltage and electrical alternans, and echocardiography showed a large circumferential pericardial effusion with right ventricular diastolic collapse indicative of tamponade physiology. A pericardial drain and left chest tube were placed, both with return of sanguineous fluid. Chest imaging following drainage of the pleural effusion revealed a mass involving the lingula and left lower lobe, and pericardial fluid cytological analysis demonstrated malignant cells consistent with adenocarcinoma. Video-assisted thoracoscopy and pericardial window were performed, and pleural and pericardial biopsies confirmed lung adenocarcinoma. Tuberculosis was ruled out with negative sputum cultures for acid-fast bacteria and lack of adenosine deaminase in the pleural fluid. Given the advanced stage of his disease, the patient opted for palliative chemotherapy with carboplatin and pemetrexed.

DISCUSSION: Acute pericardial disease as a presenting sign of a previously undiagnosed malignancy has an incidence of 4-7% and is rarely complicated by tamponade. Malignant pericardial effusions are most commonly associated with primary lung cancer and generally confer a poor prognosis. Patients presenting with both pleural and pericardial effusions are more likely to have a malignancy than patients presenting with pericardial effusions alone.

CONCLUSIONS: Hemorrhagic pericardial effusion accompanied by tamponade physiology is a rare presenting sign of an undiagnosed malignancy. In previously healthy patients presenting with symptomatic pericardial and pleural effusions, malignancy must be strongly considered on the differential diagnosis.

Reference #1: Imazio M, et al. Relation of Acute pericardial disease to malignancy. Am J Cardiol 2005; 95:1393

Reference #2: Ben-Horin S, et al. Large symptomatic pericardial effusion as the presentation of unrecognized cancer: a study in 173 consecutive patients undergoing pericardiocentesis. Medicine (Baltimore) 2006; 85:49.

Reference #3: Spiro SG, et al.Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest. 2007 Sep

DISCLOSURE: The following authors have nothing to disclose: Adnan Khalif, Debjit Saha, Brad Butcher, Dr. Bryan Robertson

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