Case Presentation : Case Presentation Dr.kailash raj
FCPS-2 Trainee
Slide 2: 73 Year old male Zubaid abbasi was admitted thru A&E on 23nov2010 with
Shortness of breath 08days
High grade fever 08days
Loose Motion &Vomiting 05days
According to pts attendant he was in his usual state of health that 8days back he started developing SOB that was aggravated on walking & lying down and relieved by sitting and leaning forward. It was associated with high grade fever sudden in onset associted with sweating and rigors for that he took antipyretics at home, besides he also had vomiting and watery loose motions; not having blood, pus or mucus.No H/O Chest pain. He was admitted at ashfaq memorial hospital for 3 days for above mentioned complaints but got no relief and rushed here.
Slide 3: PMHx:
Lt Sided Pneumonia Dec 2009
Treated with Antibiotics and advised bronchoscopy but was not done PSHx:
Not Significant Personal Hx:
Dec: Appetite
Regular Bowel Habits
Normal Micturation
Ex-smoker
No History of Wt:loss
Drug History : Drug History Medications:
Inj: Klaricid
Tb. Fexet
Tb zentro
Tb colchine
Syp. Pulmonale
Slide 5: Family Hx:
Not Significant Socio-economic Hx:
Fair
General Physical Examination : General Physical Examination Old aged Male; anxious tachypenic; sitting leaned forward oriented to TPP.
Examination:
A-ve, J-ve, Clubbing-ve, Cyanosis-ve Dehydration+ve, Bilateral Pedal Edema, Lymph nodes not Plapable, JVP Raised
HR = 116 – reg / RR = 28 / BP = 130/90
SpO2 = 96% with oxygen / T = 98.6F
Systemic Examination : Systemic Examination Chest Examination - “Good AE – R>L, B/L crepts; more on lt side”
CVS Exam- S1+ S2 Muffled
No added sounds
No rub CNS Examination - Intact
Abdominal Exam- Soft, Distended &NonTender - BS present
Differential Diagnosis : Pericarditis
Pneumonia
Gastroenteritis
Pericardial effusion
Cardiac temponade
Sepsis Differential Diagnosis
Investigation : Investigation CBC =
13.4 / 29.2 / 182 Neut = 93%
UCE=
Na= 119 K+= 3.7 CL:96 Bicar=17
Urea= 176 Crt=1.8
LFTs =
Bilirubin = 5.3 conjugated 2.5
AST= 680 ALT = 1665 ALP = 395 GGT = 175 Albumin = 3.0
PT= 54(13) APTT=30(30)
RBS
168
Slide 10: Pericardial fluid:
Gram Stain: No organism seen
Culture: NoGrowth
AFB Smear:
AFB Not Seen
D/R: not possible due to pus Specimen
AFB Culture:
Awaited
Slide 11: ECG:
Rate:110/min sinus rhythm, low voltage QRS complexes, no ST-T wave changes
Echo:
Normal size LV with Preserved systolic function
Normal valves
Moderate sized pericardial effusion surrounding whole heart
EF: 55%
Slide 12: CXR:
Cardio-megaly
Lt Sided consolidation
U/S:
B/L Grade 1 renal parynchymal changes
Lt Sided Pleural effusion
Pericardial Effusion : Pericardial Effusion
Pericardial Effusion : Pericardial Effusion Presence of abnormal amount of fluid in the pericardial space
Normally 15-50 mls of fluid
Function – minimise friction between visceral and parietal pericardial layers
Arises from visceral pericardium
Essentially an ultrafiltrate of plasma
Pericardial Effusion : Pericardial Effusion Clinical manifestations vary with rate of accumulation
Rapid accumulation -> elevated intracardiac pressure with 80mls
Slow accumulation -> elevated intracardiac pressure may not occur until 2 litres
Pericardial Effusion : Pericardial Effusion Race
No consistent difference among races is reported in the literature.
AIDS patients with pericardial effusion are more likely to be white.
Sex
No sexual predilection exists.
Age
Observed in all age groups
Mean occurrence in fourth or fifth decades; earlier in patients with HIV.
Clinical Presentation : Clinical Presentation Patient with pericardial effusion may report the following symptoms:
Cardiovascular
Chest pain, Characteristically, pericardial pain may be relieved by sitting up and leaning forward and is intensified by lying supine.
Light-headedness, syncope
Palpitations
Respiratory
Cough
Dyspnea
Hoarseness
Gastrointestinal
Hiccoughs
Neurologic
Anxiety
Confusion
Clinical Presentation : Clinical Presentation Cardiovascular
Classic Beck triad of pericardial tamponade (hypotension, muffled heart sounds, jugular venous distension).
Pulsus paradoxus: Exaggeration of physiologic respiratory variation in systemic blood pressure, defined as a decrease in systolic blood pressure of more than 10 mm Hg with inspiration, signaling falling cardiac output during inspiration.
Pericardial friction rub: The most important physical sign of acute pericarditis may have up to 3 components per cardiac cycle and is high-pitched, scratching, and grating. It can sometimes be elicited only when firm pressure with the diaphragm of the stethoscope is applied to the chest wall at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration with the patient upright and leaning forward.
Tachycardia
Hepatojugular reflux: This can be observed by applying pressure to the periumbilical region. A rise in the jugular venous pressure (JVP) of greater than 3 cm H2 O for more than 30 seconds suggests elevated central venous pressure. Transient elevation in JVP may be normal.
Clinical Presentation : Clinical Presentation Respiratory
Tachypnea
Decreased breath sounds (secondary to pleural effusions)
Ewart sign - Dullness to percussion beneath the angle of left scapula from compression of the left lung by pericardial fluid
Gastrointestinal - Hepatosplenomegaly
Extremities
Weakened peripheral pulses
Edema
Cyanosis
Pericardial Effusion : Pericardial Effusion Causes- Infectious – bacterial, viral, fungal, parasitic, TB, HIV related- Autoimmune & connective tissue disorders e.g. rheumatoid arthritis, SLE- Trauma- Neoplastic- Radiation- Hypothyroidism
Drugs
Uraemia
Effusion & Tamponade : Effusion & Tamponade
Pericardial Effusion : Pericardial Effusion InvestigationsCXR – Enlarged cardiac silhouette -- Pericardial fat stripe“CXR is unreliable in establishing or refuting diagnosis of pericardial effusion”
Pericardial Effusion : Pericardial Effusion
Pericardial Effusion : Pericardial Effusion Investigations- CT Chest – may detect as little as 50mls of fluid- General data suggests fewer false positives than echocardiography- Disadvantage – transport of pt to CT scanner especially if unstable
Pericardial Effusion : Pericardial Effusion Investigations- MRI – can detect as little as 30mls- Transport and time taken to scan are major issues- ECG – Classic findings – low voltages, electrical alterans - Studies suggest ECG poor diagnostic tool
Pericardial Effusion : Pericardial Effusion Echocardiography- Doppler echocardiography is recommended in all patients in whom pericardial effusion or cardiac tamponade are suspected
Gold standard- Large effusions seen as echo free spaces between visceral and parietal pericardium- Large effusions -> diastolic collapse of RA and RV, signalling tamponade- Large effusions are classified as > 1cm on echocardiography- Increasingly used in combination with pericardiocentesis
Pericardial Effusion : Pericardial Effusion Management- Pericardiocentesis - used commonly with agitated saline to determine if needle is in ventricle - Connection of ECG lead to needle “Electrical activity” seen on monitor when comes into contact with myocardium
Pericardial Effusion : Pericardial Effusion
Pericardial Effusion : Pericardial Effusion Complications of pericardiocentesis include ventricular rupture,
Dysrhythmias,
Pneumothorax,
Myocardial and/or coronary artery laceration, and infection.
Recurrence rates within 90 days may be as high as 90% in patients with cancer
Management : Management Initially, medical care of pericardial effusion is focused on determination of the underlying etiology.
Aspirin/nonsteroidal anti-inflammatory agents (NSAIDs)
Most acute idiopathic or viral pericarditis occurrences are self-limited and respond to treatment with aspirin (650 mg q6h) or another NSAID.
Indomethacin should be avoided in patients who may have coronary artery disease.
Slide 31: The routine use of colchicine is supported by results from the COlchicine for acute PEricarditis (COPE) trial.
In this trial, 120 patients with a first episode of acute pericarditis (idiopathic, acute, postpericardiotomy syndrome, and connective tissue disease) entered a randomized, open-label trial comparing aspirin treatment alone with aspirin plus colchicine (1-2 mg for the first day followed by 0.5-1 mg/d for 3 mo). Colchicine reduced symptoms at 72 hours (11.7% vs 36.7%; P =0.03) and reduced recurrence at 18 months (10.7% vs 36.7%; P =0.004; 5 needed treatment). Colchicine was discontinued in 5 patients because of diarrhea. No other adverse events were noted. Importantly, none of the 120 patients developed cardiac tamponade or progressed to pericardial constriction.16
Slide 32: Steroids:
Steroid administration early in the course of acute pericarditis appears to be associated with an increased incidence of relapse after tapering the steroids.
Systemic steroids should be considered only in patients with recurrent pericarditis unresponsive to NSAIDs and colchicine or as needed for treatment of an underlying inflammatory disease. If steroids are to be used, an effective dose (1-1.5 mg/kg of prednisone) should be given, and it should be continued for at least 1 month before slow tapering.
Slide 33: Hemodynamic support
Hemodynamic monitoring with a balloon flotation pulmonary artery catheter is useful, especially in those with threatened or mild tamponade.
Intravenous fluid resuscitation may be helpful in cases of hemodynamic compromise.
In patients with tamponade who are critically ill, intravenous positive inotropes (dobutamine, dopamine) can be used but are of limited use and should not be allowed to substitute for or delay pericardiocentesis.
Slide 34: Antibiotics
In patients with purulent pericarditis, urgent pericardial drainage combined with intravenous antibacterial therapy (eg, vancomycin 1 g bid, ceftriaxone 1-2 g bid, and ciprofloxacin 400 mg/d) is mandatory. Irrigation with urokinase or streptokinase, using large catheters, may liquify the purulent exudate, but open surgical drainage is preferable.
The initial treatment of tuberculous pericarditis should include isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, and ethambutol 15-25 mg/kg/day.
Slide 35: Surgical Care
Subxiphoid pericardial window with pericardiostomy.
This procedure is associated with low morbidity, mortality, and recurrence rates, and can be considered as a reasonable alternative diagnostic or treatment modality to pericardiocentesis in selected patients.
Thoracotomy
This should be reserved for patients in whom conservative approaches have failed.
It allows for creation of a pleuropericardial window, which provides greater visualization of pericardium.
Video-assisted thoracic surgery
Video-assisted thoracic surgery (VATS) enables resection of a wider area of pericardium than the subxiphoid approach without the morbidity of thoracotomy.
Slide 36: Mortality/Morbidity
The mortality and morbidity of pericardial effusion is dependent upon etiology and comorbid conditions.
Idiopathic effusions are well tolerated in most patients. As many as 50% of patients with large, chronic effusions were asymptomatic during long-term follow-up.
Pericardial effusion is the primary or contributory cause of death in 86% of cancer patients with symptomatic effusions.
Survival rate for patients with HIV and symptomatic pericardial effusion is 36% at 6 months, 19% at 1 year
Slide 37: Thanks