Massive Pericardial Effusion

Muh. Yogi Pratama C111 09 752

Advisor : dr. Juzny Alkatiri, SpPD, SpJP. FIHA
Department of Cardiovascular Disease Faculty of Medicine Hasanuddin University 2013

Patient Identity
Name

Age
MR Address

: Mrs. HP : 36 yo : 627779 : Masamba, Central : Shopkeeper : Sept, 13th 2013

Sulawesi Occupation Date of Admission

History Taking
Shortness of Breath
Progressively since 6 months ago, worsen 1 months

before admission appears when lie down Decrease when sitting or stand up Shortness of Breath during activity (-)
Chest Pain
Predominantly come and go since 2 weeks before

admission, mostly accompanied by SOB. Pressed-like sensation on left chest radiating to the back. Pain got worsen when lie down and take a breath. And relieved when sitting or stand up.
Coughing
Sometimes happens since 1 months before admission,

sputum (+) white-yellowish color

 Cold Sweating sometimes happened since 6 months

ago, during night time, chills (+), fever (-) Weight loss (+) 15 kg progressively since 6 months ago Difficulties on swallowing (-), Nausea (-), vomiting (-), epigastric pain (-), Abdominal discomfort (+) No abnormalities on defecation and urination

Past Medical History

History of HT (-), DM (-), Allergy (+) pennicilin History of Previous disease (+), thyroid nodule 13

years ago (thyroidectomy(+)) History of Long Contact with TB patient (+) History of smoking (-) History of Same complaints on family (-)

PHYSICAL EXAMINATION
Status Present : Moderate illness/ underweight /composmentis VAS : 2/10 Vital Sign :

- Blood Pressure :90/60 mmHg - Pulse :72 bpm Regular - Inspiratory rate :26 bpm regular - Body temperature:36,70C (Axillary) Head Examination - Eyes : Anemis +/+, icterus -/- Lip : Cyanosis (-) - Neck : No mass, no tenderness, JVP R +3 cmH2O Chest Examination - Inspection : Symmetric - Palpation : Mass (-), Tenderness (-) - Percussion : Sonor - Auscultation : Breath sound :Vesicular Additional sound : Ronchi -/-, Wheezing -/-

PHYSICAL EXAMINATION
Cardiac Examination
Inspection Palpation Percussion

: Ictus cordis was not visible : ictus cordis was not palpable : Superior: ICS II S Inferior: ICS V

Sinistra : Lin. Mid axillaris Dextra : Lin. Parasternalis D Auscultation : HS I/II Regular, Muffled heart sound (+) on apex area. Friction rub (-)
Abdominal

- Inspection - Auscultation - Palpation Hepar - Percussion Extremities

: Normal : Peristaltic sound (+), normal : Pain (-), Mass (-), tenderness (-) and spleen unpalpable : tymphani, ascites (-) : No oedema

LABORATORY ASSESMENT (16/09/13)

COMPLETE BLOOD COUNT
WBC : 11.5.103 /mm3
RBC : 4,35.

BLOOD CHEMISTRY ASSESMENT

GDS : 67 mg/dL Ureum : 26 mg/dL Creatinin : 0.9 mg/dL SGOT : 45 U/l SGPT : 29 U/l Albumin : 3.4U/l Total Protein : 6.4 g/dl

106/mm3

HGB : 13.2 g/dl

HCT : 40.6 %
PLT : 166. 103/l

LABORATORY ASSESMENT
ELECTROLYTE Natrium : 137 mmol/l Kalium : 3.8 mmol/l Cloride : 100 mmol/l HBsAg Non Reactive Anti HCV Non Reactive

ECG

Interpretation
Rhythm QRS rate Regularity PR interval Axis

P wave
Complex QRS ST Segment

T wave
Conclusion

: Sinus Rhtym : 75 bpm : Regular : 0.16 s : +100o :: Low QRS wave all leads : Normal :: Sinus Rhytm, Low QRS wave

Chest X-Ray
22/8/13 19/9/13

Echocardiography

Interpretation

Systolic function of LV are good, EF 80% LVH (-) Dimension of Heart chambers: Normal Global normokinetic RV function are good, TAPSE: 2.6 cm Heart Valves :

Mitral: MR Trivial Aorta: 3 cusps, Calcification (-) Tricuspid : Function and mobility are good Pulmonal : Function and mobility are good

E/A >1 PE 4-5 cm Conclusion : Systolic function of LV was good, EF 80%,

MASSIVE PE

Aspiration of Pericardial Fluid

14/09/2013
500 cc Transudate Recommendation : Pericardial fluid aspiration per day Administration of antibiotic Further analysis, Cytology analysis, and microbiology culture

Pericardial Fluid Analysis (16/9/13)

Color Volume

: Red, turbid : 53 : None : 1.005 :8 : Negative 1-10 None <1.08

Clear

Coagulation
BJ Ph Rivalta

Negative Glucose : 90 Protein : 6.3 LDH : 444 Cell : 200 Diff.count : PMN 16%, MN 84%

<200 <3 100-190

N <25

Cytology Analysis (19/9/13)

Conclusion: Proliferative mesothelial cells + inflammatory lesions

DIAGNOSIS
MASSIVE PERICARDIAL EFFUSION E.C SUSP. LUNG TUBERCULOSIS

Management
Tapping of pericardial fluid per day

Insertion of Connecta
Ceftriaxone 2gr/24hours/iv Methylprednisolon 125mg/12hours/iv

Further Examinations
Sputum Examinations for M. Tuberculosis

Discussion
PERICARDIAL EFFUSION

Pericardial Effusion
Presence of an abnormal amount of fluid and/or

an abnormal character to fluid in the pericardial space. Fluids may be transudative, exsudative, pyopericardium, or hemopericardium. It can be caused by a variety of local and systemic disorders, or it may be idiopathic

Pericardium
Formed by 2 layers, visceral and fibrous.

Pericardium functions as a barrier of protection

from infections and infflamations of the surrounding organs. Normal volume of fluids : 15-50 ml, secreted by mesothelial cell. Accumulation of fluids leads to effusion, and progress into the incerease of pericardial pressure (N: -5mmHg - +5mmHg), cardiac output, and hypotension (cardiac tamponade).

Etiology of PE

Pericarditis, Spesific: 1. Microorganism infection 2. Idiopathic Inflammation 3. Inflammation from heart surgery or heart attack (Dressler Syndrome) 4. Autoimmune 5. Kidney Failure (Uremic) 6. Hypothyroidism 7. Metastatic 8. Radiation 9. Trauma 10. Drugs (Isoniazid, Phenytoin)

Pathophysiology
Pericardium could be infected by m.tb on

hematogenous, lymphogenous or by direct spread. It might happens without the clinical manifestation of pulmonary or EP Tuberculosis It spreads from an infection on mediastinal to pericard, mainly on a branch of bronchotracheal.

1. Fibrinous stadium

Wide fibrous deposit and granuloma reaction, no clinical signs.

Hypersensitivity reaction towards tuberculoprotein Forms of effusion in pericardium Surface of pericard becomes grayish and shows an exudative sign. Effusion develops into 4 phase (Serous, seroanguinous, turbid, blood). Increase of PMN and Protein, Decrease of Glucose shown. Massive effusion happens at this stage (4 L).

2. Effusion stadium

3. Absorption stadium

Forms of fibrin and collagens, fibrous tissue on pericard, thickened layers and caseous granuloma founded. Thickness of parietal layer, constriction of miocard limits the movement of heart chambers.

4. Thickness of Parietal Layers.

PERICARDIAL DISEASE

PERICARDIAL EFFUSION
Symptoms:

70 % Asymptomatic (without tamponade) Chest Pain (Pressed-like pain) Dyspneu Coughing Dysphagia Hiccup Hoarseness Sense of abdominal fullness

PERICARDIAL DISEASE

PHYSICAL EXAMINATION
Signs:

Tachycardia Increase of Jugular Pressure Muffled heart sounds

Ewarts sign: Patch of dullness on percussion and bronchial breathing on auscultation, between the vertebral column and the scapula, caused by compression of left lung base by pericardial fluid

DIAGNOSTIC EVALUATION
Lab: CBC, Liver and kidney function, thyroid, PCR, Heart enzyme, RF, Cyctology, and fluid analysis (culture, cell count and cytology)

Chest X-Ray : Water Bottle Heart appearances (fluid>250ml), pleural effusion may also visible)

ECG: Tachycardia, low QRS wave, Narrowed ST, electrical alternans.

ECHOCARDIOGRAPH

Pericardial Tamponade

Fluid necessary to cause P. Tamponade: 200 2000 ml (depends upon the rate of accumulation)

PERICARDIAL DISEASE

PERICARDIAL TAMPONADE

Clinical Features:
Dyspnea, orthopnea and fatigue Tachycardia Decreased systolic blood pressure with narrow pulse

pressure

Pulsus Paradoxus
Elevated venous pressure and hepatic engorgement Heart sounds muffled Ewart sign may be present Diastolic equilibration of pressures in all cardiac chambers

on cardiac catheterization

PERICARDIAL DISEASE

PERICARDIAL TAMPONADE
Becks Triad:
Decreased arterial pressure

Increased venous pressure

Quiet heart/Distant Heart Sounds

Management
A. Treat the underlying disease B. Pharmacotherapy for pericardial effusion includes use of the following agents, depending on the etiology: NSAIDs (eg, indomethacin, ibuprofen, naproxen, diclofenac, ketoprofen, aspirin) Corticosteroids (eg, prednisone, methylprednisolone, prednisolone) Anti-inflammatory agents (eg, colchicine) Antibiotics (eg, vancomycin, ceftriaxone, ciprofloxacin, isoniazid, rifampin, pyrazinamide, ethambutol) Antineoplastic therapy (eg, systemic chemotherapy, radiation)

 C. Invasive procedures:

Pericardiosentesis Aspiration of the fluid by small incision below sternum, or intercostal at left thoracal area. Pig tail catheter can be applied for 2-3 days. This process will happen until the amount of fluid taken less than 50ml/day. This periods will give amount of time for the aposition and adhesion of the pericard Reccurency: 6-12% Complication:

Management

Management
D. Pericardiectomy
Surgery procedure by opening the pericardium to

drain the excessive fluid. Indication: recurrent effusion, massive with cardiac tamponade, pacemaker. CI: Infectious pericarditis, malignancy

THANK YOU FOR YOUR ATTENTION

References: 1. Eva Roswati, Zainal Safri. Pericardioentesis pada pasien dengan Pericardial effusion. Divisi Kardiologi, USU. 2012 2. Shabetai R. Disease of the pericardium. In: Hurst J, editor. The heart. New York: McGraw-Hill; 1986. p. 1249-50. 3. Hageman JH, DEsopo ND, Glenn WW. Tuberculosis of the pericardium: A long term analysis of 44 proved cases. N Engl J Med. 1964;270:327-31. 4. Jaume Sagrista-Sauleda. Diagnosis and Management of Pericardial Effusion. Ncbi. 2011.