Effusion and coin shadow: is there a relation? A case report

Malignant pericardial effusion is a common consequence of various types of cancer. The diagnosis of cardiac tamponade in malignant effusion may be challenging, as the typical echocardiographic signs are not met. Patients with cancer can present with cardiac tamponade in form of tachycardia (rather that hypotension) that improves after pericardiocentesis.

A 70-year-old female patient presented to the emergency department with rapid development of shortness of breath over a week. Her past medical history included oesophageal carcinoma 1 year before presentation. This was complicated by dysphagia for which the patient underwent oesophageal stenting 5 months before admission. On admission, the patient was in respiratory distress, tachycardia; however, she was normotensive. Echocardiography revealed massive circumferential pericardial effusion. Apart from significant respiratory variation in mitral and tricuspid inflow, the echocardiographic features of tamponade were absent. We discuss on how we applied European Society of Cardiology guidelines in order to calculate the pericardiocentesis score and make a firm management plan. Despite that the patient was normotensive, the pericardiocentesis score was 13.5, so urgent pericardiocentesis was done followed by immediate improvement.

This case demonstrates that oncology patients can present with tamponade in the form of tachycardia rather than hypotension as the slow course of effusion formation allows the body to compensate by increasing the heart rate and peripheral vascular resistance, thus maintaining the blood pressure. The application of ‘pericardiocentesis score’ is very helpful in such patients. Score equal or greater than 6 necessitates urgent pericardiocentesis even if the blood pressure is normal.