Pleural and Pericardial Effusion With COVID-19 and Systemic Lupus Erythematosus and Its Recurrence: A Case Study.

As a chronic autoimmune disease, systemic lupus erythematosus (SLE) primarily affects young women and does not discriminate against any particular organs. In December 2019, coronavirus disease 2019 (COVID-19) spread worldwide, with many speculations of cardiac involvement in the pathogenesis of infection. Moreover, in cases where cardiac symptoms were described, they consisted solely of chest pain or a general deterioration in health if the patient presented with pleural effusion or pericardial effusion. Our patient, a 25-year-old Hispanic woman, initially complained of chest pain, cough, and shortness of breath. After being admitted, she noticed growing dyspnea and mild discomfort on the right side of her chest. The patient had both SLE and COVID-19 and had developed pleural and pericardial effusions. After two days in culture, nothing had grown from the fluid samples. In addition, measures of brain natriuretic peptide and total creatine kinase fell within the normal range. Considering the investigational findings, pericardiocentesis was performed. After the procedure, the patient's condition improved, and she was discharged. The patient continued taking CellCept® 1,500 mg and Plaquenil 200 mg and started taking colchicine. Her daily prednisone dose was increased to 40 milligrams. She felt well initially; however, after two weeks of follow-up, the pericardial effusion recurred, and pericardiocentesis was performed again. The patient was discharged in stable condition after a two-day hospital stay. After treatment of both initial and recurrent effusions, the patient's cardiac symptoms were resolved, and blood pressure became stable. We hypothesize that there may be other unreported cases of COVID-19-related viral pericarditis, pericardial effusion, and pericardial tamponade that could be caused by a combination of COVID-19 and a pre-existing condition, mainly autoimmune disorders. Due to the lack of clarity surrounding typical COVID-19 manifestations, it is crucial to record all cases of this unique illness and analyze any increased incidence of pericarditis, pericardial effusion, and pericardial tamponade in the public.

Clinical outcome of patients with severe malignant pericardial effusion due to neoplastic disease undergoing percutaneous balloon pericardiotomy during COVID-19 pandemic

Background: Neoplastic pericardial effusion (NPE) is a serious complication that occurs in the setting of advanced oncological disease and is associated with a high recurrence rate. Currently, pericardiocentesis (PCT) remains the first therapeutic option and the use of percutaneous balloon pericardiotomy (PBP) is limited to the treatment of recurrences. However, it is not known whether some aspects of the procedure during PBP lead to different outcomes in terms of survival and recurrence, and no such patients have been included in studies during COVID-19 pandemic. Purpose(s): The aim is to analyses the success, complications and recurrence rate (defined as recurrence of NPE requiring PCT, PBP or surgical pericardial window (SPW) of both procedures (BP) in order to establish the optimal entry treatment for these patients. Method(s): This research analyzed the clinical characteristics and prognostic factors of patients with severe pericardial effusion of neoplastic etiology who underwent PBP during the COVID-19 pandemic. A prospective study was conducted involving 23 patients admitted between January 2020 and January 2022 for severe NPE who underwent PCT or PBP as initial treatment of NPE. Result(s): We included 23 patients, 62.9% were male with a mean age of 51.2+/-14.9 years NPE was the first manifestation of the oncological process in 12 patients (52.1%) with lung cancer being the most frequently associated primary cancer (58.7%) followed by breast cancer in 12.7% of cases. A total of 26 procedures were performed, 10 PCT, 15 PBP, 1 SPW, with tumors cells identified in the pericardial fluid in 13.0% of cases. PCT was used as an entry point in 10 patients (43.5%), 6 patients were COVID-19 positive and PCT was performed as the first treatment. While PBP was chosen as the first therapeutic option in 13 patients (56.5%) (2 Re-PBP). The initial efficacy of the procedure was 93.1% and 92.2% respectively (p=0.88), with 1 complication occurring in the PBP group but not requiring scheduled SPW. In the former group, the percentage of recurrences was higher (34.7%;8 recurrences in 10 patients) compared to patients treated with upfront PBP (8.6%;2 recurrences in 13 patients), p=0.09. In addition, only one patient had to resort to surgery. When analyses according to the BP. used, the recurrence rate was 4.0 times higher for PCT (34.7 vs. 8.6% recurrences), although without reaching statistical significance (p=0.16). Conclusion(s): The PBP is a simple, safe and effective technique for the treatment of NPE during the COVID-19 pandemic, in our series it was associated with a lower recurrence rate. Therefore, it could replace PCT in these patients during the COVID-19 pandemic as optimal first line treatment, providing better quality of life and reducing the need for re-interventions. (Figure Presented).

Purulent pericarditis caused by methicillin-sensitive Staphylococcus aureus in an immunocompetent adult after COVID-19 pneumonia: a case report.

Background: SARS-CoV-2 has been implicated in many cardiac pathologies, manifesting mainly as acute. However, acute purulent pericarditis is exceedingly rare in the antibiotic era. Though, few studies have associated it with long-COVID, prompt recognition and treatment are crucial. Case summary: A 61-year-old immunocompetent woman presented with a left lower limb pitting oedema 1 month after COVID-19 pneumonia. Following clinical, laboratory, and imaging work-up, the patient was found to have deep vein thrombosis of the anterior and posterior tibial and gastrocnemius veins. Owning to persistent sinus tachycardia, an additional work-up was performed, which revealed a large pericardial effusion. Pericardiocentesis drained the frank pus, and subsequently, empirical antibiotics therapy was initiated. Pericardial fluid cultures showed methicillin-sensitive Staphylococcus aureus (MSSA). Following the antibiotic treatment with cloxacillin 6 × 2 g IV for 6 weeks, the patient fully recovered. Discussion: Herein, we report a rare case of bacterial pericarditis caused by MSSA 1 month after COVID-19 pneumonia. Additionally, this condition may arise as a result of immunosuppressive treatment with glucocorticoids during and after COVID-19 pneumonia. However, the causal association has not yet been confirmed.

Purulent Pericardial Effusion with a Swinging Heart Post-Sars-Cov-2 Infection: A Case Report

Background Acute bacterial pericarditis is rare and can decompensate quickly to cardiac tamponade and cardiac arrest. Targeted antibiotic therapy, pericardiocentesis, and pericardiotomy are the cornerstones of management. Case 51-year-old male presented with 2-weeks of progressive chest pain, cough, and fatigue. A month prior he tested positive for COVID-19. On exam he was tachycardiac, tachypneic, and normotensive. JVD and peripheral edema were present. Labs revealed elevated WBC, BNP, HS-troponin, and ESR/CRP. Blood cultures were positive for methicillin susceptible Staphylococcus aureus (MSSA). Echo showed a large pericardial effusion with a swinging heart. ECG showed diffuse ST elevations and PR depression. He was not clinically in tamponade but shortly after became bradycardic and had a PEA arrest. Emergent bedside pericardiocentesis was performed, and after 9-minutes of ACLS, ROSC was attained. Pericardial fluid grew MSSA. Decision-making Vancomycin and cefepime were started and tapered to cefazolin to cover MSSA bacteremia and pericarditis. Repeat blood cultures were negative. A month after discharge he had no cardiac symptoms and echo showed minimal pericardial fluid. Conclusion In patients with COVID-19 and pericardial effusion, bacterial pericarditis can be secondary to contiguous spread from lung parenchyma or myopericarditis with superimposed infection, or due to primary pericarditis. This is the second reported case of spontaneous purulent pericarditis with MSSA. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

A Unique Case of Pericardial Effusion and Tamponade

Background We present a unique case of a female who developed a large pericardial effusion (PEff) from a rare cause. Case A 36-year-old female with recent COVID-19 infection presented with acute dyspnea. She had undergone liposuction, rectus plication and breast augmentation two months ago. Heart rate was 90/min and blood pressure 86/57mmHg. CT angiogram of the chest revealed a massive PEff with tamponade. She had large right-sided pleural effusion also. She underwent ultrasound-guided pericardiocentesis with the removal of 950 milliliters of serosanguineous fluid. Follow-up echocardiogram showed re-accumulation of fluid. Due to the rapid onset of PEff, she underwent a pericardial window and bilateral chest tube placement. Decision-making Pleural and pericardial fluid analysis showed silicone-gel particles (Figure. 1). Pericardial biopsy showed nonspecific chronic inflammation. Autoimmune workup was unremarkable. Elevated ESR and CRP in the presence of embolized gel particles indicated foreign body reaction from silicone embolism. Plastic surgery advised implant removal. Silicone embolism is known to cause silicone thorax, pleural effusions, and anaplastic large cell lymphoma. To our knowledge, this is the first reported case of PEff due to silicone embolism from breast implants. Conclusion Cardiologists should be aware of this rare but serious complication. Silicone embolism should be considered in the differential of PEff in patients with breast implants. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Streptococcus Pneumoniae Purulent Pericarditis

Background Bacterial pericarditis represents < 1 % of all cases of pericarditis in the United States. Most cases of bacterial pericarditis are from contiguous spread from underlying pneumonia or mediastinitis. We present a case of pneumococcal pericarditis in a patient with untreated pneumonia. Case A 54-year-old male with a past medical history of recent COVID-19 pneumonia presented with worsening dyspnea for the past 3 weeks. Vitals were T 99.3, BP 122/93, HR 159 BPM, O2 sat 94% on 3 L NC. ECG demonstrated atrial flutter with 2:1 block. CT scan demonstrated a pericardial effusion and bilateral pleural effusions. Decision-making In the ED, he became hypotensive and bedside echo demonstrated large pericardial effusion with RV collapse. Emergent pericardiocentesis produced 750 cc of purulent fluid. Streptococcus pneumoniae was isolated from the initial fluid aspirate. Right thoracostomy tube was placed with pleural fluid gram stain and culture without bacterial growth. Due to continued purulent drainage from the pericardial drain, repeat CT scan demonstrated persistent pericardial effusion and loculated right sided pleural effusion. He underwent video-assisted thoracoscopic surgery with pericardial wash out and window. He improved and was discharged with 6 weeks of Ceftriaxone. Conclusion Purulent pericarditis is typically a fulminant disease associated with high mortality and rapid progression. Prompt identification and management is critical for patient survival. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Pericardial Fluid in a COVID-19 Patient: Is It Exudate or Transudate?

BACKGROUND: Very limited information is available on pericardial effusion as a complication of COVID-19 infection. There are no reports regarding pericardial fluid findings in COVID-19 patients. CASE DESCRIPTION: We describe a 41-year-old woman, with confirmed COVID-19, who presented with a large pericardial effusion. The pericardial fluid was drained. We present the laboratory findings to improve knowledge of this virus. DISCUSSION: We believe this is the first such reported case. Findings suggested the fluid was exudative, with remarkably high lactate dehydrogenase and albumin levels. We hope our data provide additional insight into the diagnosis and therapeutic options for managing this infection.LEARNING POINTS: Laboratory findings of drained pericardial fluid in a patient with COVID-19 are presented.The clinical presentation of pericardial involvement in COVID-19 infection and the role of echocardiography in diagnosis and management are described.

Primary Cardiac Lymphoma with an Aggressive Hostile Take-Over

Background Primary cardiac lymphoma (PCL) is an extranodal lymphoma involving only the heart and/or pericardium. PCL accounts for 2% of primary cardiac tumors and 0.5% of extranodal lymphomas. Its diagnosis is usually delayed due to rarity and non-specific findings. Case A 77-year-old man with Alzheimer dementia, atrial fibrillation on apixaban, and COVID-19 illness 3-weeks prior, who presented to the hospital with diffuse abdominal discomfort, fatigue, anorexia, and hypoactivity. Patient was tachycardic and normotensive with pronounced jugular venous distention, non-collapsing with respiration. ECG revealed sinus tachycardia, first degree atrioventricular (AV) block and chronic LBBB. Cardiac troponins were mildly elevated without significant delta. An abdominopelvic CT revealed an incidental, large pericardial effusion (PE). Bedside echocardiogram confirmed a large hemodynamically significant PE as well as a mass-like echogenicity encasing and infiltrating the pericardium and myocardium at the basal aspect of the right ventricle free wall. Decision-making In view of recent COVID-19 infection, he was started on indomethacin and colchicine for suspected viral or neoplastic pericarditis. Pericardiocentesis drained 900ml of amber to serosanguineous fluid with quick hemodynamic improvement. Fluid analysis was non-diagnostic for neoplasia. Subsequently, he developed symptomatic bradycardia with an intermittent complete AV block with junctional escape rhythm, transitioning to a second-degree AV block after removal of beta-blocker. Awaiting permanent pacemaker implant, he developed ventricular fibrillation with sudden cardiac death that required prolonged unsuccessful ACLS. Autopsy revealed an extensive infiltrative tumor, predominantly right-sided, consistent with primary cardiac B-cell lymphoma. Conclusion PCL should be part of the working diagnosis in patients presenting with a pericardial effusive process in combination with a right sided myocardial mass. Early cardiac MRI/PET scan or biopsy should be considered when the diagnosis is not certain. Prompt diagnosis could allow for treatment that potentially prolongs survival.Copyright © 2023 American College of Cardiology Foundation

A rare complication of pericardiocentesis: Pneumopericardium.

Pneumopericardium is the presence of air in the pericardial sac. Pneumopericardium after pericardiocentesis has been rarely reported in the literature. In the present case, we report a patient who presented with tamponade physiology during COVID-19 and developed pneumopericardium after emergency pericardiocentesis. Immediate recognition and treatment are crucial and chest x-ray, thorax computerized tomography, and transthoracic echocardiography (TTE) are used for diagnosis.

Potential Cardiac Tamponade Development Secondary to SARS-CoV-2 Infection

Upon initial discovery in late 2019, severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, has managed to spread across the planet. A plethora of symptoms affecting multiple organ systems have been described, with the most common being nonspecific upper respiratory symptoms: cough, dyspnea, and wheezing. However, the cardiovascular system is also at risk following COVID-19 infection. Numerous cardiovascular complications have been reported by physicians globally, in particular cardiac tamponade Physicians must hold a high index of suspicion in identifying and treating patients with cardiac tamponade who may have contracted the novel coronavirus. This review will describe the current epidemiology and pathophysiology of SARS-CoV-2 and cardiac tamponade, highlighting their clinical course progression and the implications it may have for the severity of both illnesses. The paper will also review published case reports of cardiac tamponade, clinical presentation, and treatment of this complication, as well as the disease as a whole. © 2022 Elsevier Inc.

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.

Cardiac tamponade as the first presentation of thymoma: A case report during COVID-19 pandemic

We report a case of neoplastic cardiac tamponade, a life-threatening condition, as the initial presentation of an anterior mediastinal malignancy. A 69-year-old gentleman with no known history of malignancy presented to the emergency department with shortness of breath, reduced effort tolerance and chronic cough. Clinically, he was not in distress but tachycardic. He was subjected to echocardiography which revealed large pericardial effusion with tamponade effect. Pericardiocentesis drained 1.5 L of haemoserous fluid. CECT thorax, abdomen and pelvis revealed an anterior mediastinal mass with intrathoracic extension complicated with mass effect onto the right atrium and mediastinal vessels. Ultrasound-guided biopsy histopathology examination revealed thymoma. Due to locally advanced disease, tumour resection was not possible, and patient was referred to oncology team for chemoradiotherapy. We report this case study not only due to the rarity of the case but also to highlight its diagnostic challenge due to the COVID-19 pandemic. Copyright © The Author(s) 2022.

Pericardial Effusion: A Potential Late Complication of COVID-19 Infection

Purpose: COVID-19 infection involves entry of SARS-CoV-2 virus into cells via interaction between its spike protein and angiotensin converting enzyme resulting in an NF-kappabeta mediated inflammatory response. A cytokine storm may cause organ dysfunction. Cardiac manifestations without pulmonary symptoms is uncommon but has been described in the literature during an acute infection. We report a rare case of a potential late cardiac complication months after an acute COVID-19 infection. Method(s): A 62-year-old male with hypertension and end stage renal disease on hemodialysis three times a week presented with fever, arthralgia and myalgia. He denied chest pain or respiratory symptoms. Patient tested positive for COVID-19 and received conservative management only. Over the next nine months he reported persistent fatigue and new onset of shortness of breath. He continued to be very compliant with dialysis. On presentation to the hospital, all laboratory investigations, including BUN (27mg/dL) were within normal limits. Chest X- ray revealed cardiomegaly. Echocardiogram showed a large circumferential pericardial effusion without tamponade. Pericardiocentesis was accomplished with removal of 1700 ml of bloody fluid. Cell count, LDH, protein and glucose was normal. Fungal, aerobic, and anaerobic cultures of the pericardial fluid was negative. No malignant cells were detected. Patient had gradual resolution of his symptoms. Serial echocardiograms at 1, 3 and 5 months revealed a persistent small pericardial effusion. Result(s): Cardiac manifestations of SARS-CoV-2 includes myocarditis, pericarditis and pericardial effusions. In case reports, the presence of the cardiac inflammatory state occurred simultaneously with an acute COVID-19 infection. In our case the COVID-19 infection occurred over nine months earlier yet remains a plausible explanation for his hemorrhagic pericardial effusion due to the absence of other identified causes. Further, COVID-19 molecular PCR testing of pericardial testing remains low yield due to its specific development for nasopharyngeal swab sampling. Conclusion(s): Cardiac manifestations of SARS-CoV-2 infection typically occur at the time of diagnosis. A late cardiac complication of COVID-19 may include pericardial inflammation with effusion. Further data and testing needs to be developed to confirm the diagnosis and guide therapy.

TENSION PNEUMOMEDIASTINUM RESULTING IN OBSTRUCTIVE SHOCK IN COVID-19

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Pneumomediastinum is often witnessed in intensive care units secondary to mechanical ventilation, or blunt and penetrating trauma. However, it is rare for patients to develop tension pneumomediastinum. Tension pneumomediastinum within the context of Covid-19 pneumonia is even more rarely discussed. Here we discuss a patient with Covid-19 pneumonia who developed rapidly progressive tension pneumomediastinum. CASE PRESENTATION: 72-year-old male was admitted to the ICU for Covid-19 infection causing hypoxemic respiratory failure requiring mechanical ventilation. On ICU day 2 the patient developed sudden worsening of shock requiring multiple pressors. Clinical exam revealed extensive subcutaneous crepitus in the supraclavicular region extending to the neck. Chest XR showed extensive pneumomediastinum and pneumopericardium and no pneumothorax. There was concern for ongoing obstructive shock due to cardiac tamponade, cardiology was called to bedside to perform POC ultrasound. The heart could not be visualized due to subcutaneous air. CT scan showed extensive mediastinal air and subcutaneous emphysema. The significantly increasing air in the retrocardiac space and concavity of the atria were concerning for worsening tension physiology. Cardiothoracic surgery decided to place a mediastinal drain and create a pericardial window. In the hours that followed, the patient's hemodynamics improved, and his pressor requirement decreased to only low dose norepinephrine. On ICU day 3 he developed worsening severe mixed acidosis. On day 4, the patient was requiring over 100mcg per hour of norepinephrine and labs showed worsening renal and liver failure. In the afternoon of day 4, the patient experienced a cardiac arrest and expired. DISCUSSION: Most reported cases of pneumomediastinum with associated pneumopericardium are self-limited, however 38% of cases progress to create tension pneumomediastinum and life-threatening cardiac tamponade.1 There are few reports of tension pneumomediastinum complicated by pneumopericardium in patients with Covid-19,2 but there is concern that this condition occurs more frequently in critically ill patients with Covid-19.3 The management of cardiac tamponade as a result of tension pneumopericardium may include pericardiocentesis,2 placement of a pericardial window, or insertion of a mediastinal drain.3 While several reported patients who underwent these procedures survived to discharge successfully,1,3 there are also reports that suggest that the development of subcutaneous emphysema and pneumomediastinum may be indicative of worsening prognosis.3 CONCLUSIONS: The ideal management of tension pneumomediastinum in Covid-19 is not clear and prognosis of patients who develop tension pneumomediastinum is highly varied. Further study is needed to develop tools to identify pneumomediastinum with the potential to develop tension physiology and progress to obstructive shock. Reference #1: Hazariwala, V., Hadid, H., Kirsch, D. et al. Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report. J Cardiothorac Surg 15, 301 (2020). https://doi.org/10.1186/s13019-020-01308-7 Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984;37(6):511-518. doi:10.1016/s0003-4975(10)61146-0 Reference #3: Al-Azzawi M, Douedi S, Alshami A, Al-Saoudi G, Mikhail J. Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis? Am J Case Rep. 2020;21:e925557-1-e925557-6. doi:10.12659/AJCR.925557 DISCLOSURES: No relevant relationships by Roger Alvarez, value=Travel Removed 03/30/2022 by Roger Alvarez No relevant relationships by Roger Alvarez, value=Consulting fee Removed 03/30/2022 by Roger Alvarez no disclosure on file for Michelle Hernandez;No relevant relationships by Rose Puthumana

COVID-19 CARDIAC TAMPONADE WITH CARDIOGENIC SHOCK IN A PREVIOUSLY VACCINATED YOUNG ADULT: A CASE REPORT

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Previous case reports have shown a number of cardiac complications associated with, and attributed to COVID-19 infection including acute myocardial injury and infarction, dysrhythmias, acute heart failure, pericarditis, and venous thromboembolic events, among others. Up until this point, these cases have all been documented in unvaccinated individuals 1. CASE PRESENTATION: Here we report a unique case of a 40-year-old previously vaccinated woman who presented with generalized weakness, chest pain, dyspnea, and vomiting. She was found to be septic and positive for COVID-19. Transthoracic echocardiogram showed a small pericardial effusion on admission and the patient was diagnosed with acute myopericarditis secondary to COVID-19. Within the first 24 hours following admission, the patient's condition rapidly deteriorated and she developed worsening pericardial effusion, with subsequent cardiac tamponade, and cardiogenic shock. Following attempted pericardiocentesis and surgical drainage, cardiac function did not improve and she expired soon after. DISCUSSION: Despite most of the clinical attention being focused on the effects of SARS-CoV-2 on the respiratory system and the pneumonia it causes, there have been more reported complications involving other organ systems, particularly the heart and kidneys. Studies have shown three main categories of cardiac involvement and complications related to COVID-19: myocardial injury, acute heart failure, and arrhythmia. Focusing on myocardial injuries, there have been some reports attempting to elucidate the frequency of myo- and pericarditis as complications of COVID-19. Yet still to this date, little is known about pericarditis as a COVID-19 complication. Of the case reports published thus far regarding COVID-19 pericarditis, the majority of them do not exhibit cardiac tamponade. In one systematic review published in September, 2021, a total of 33 studies including 32 case reports and one case series were included and pericardial effusion and cardiac tamponade were reported in 76% and 35% of the cases, respectively 2. To our knowledge, our case is the first of its kind, illustrating cardiac tamponade in a fully vaccinated individual. Although, there have been no clear mechanisms explaining the pathogenesis of cardiac involvement in patients suffering from COVID-19, multiple possibilities have been hypothesized. Similar to other cardiotoxic viruses, an inflammatory response is likely triggered resulting in pericarditis and pericardial effusion 3. When left unabated, cardiac tamponade can occur. CONCLUSIONS: Our case documents a reminder of the critical nature of SARS-CoV-2, even in vaccinated patients. To our knowledge, this is the first reported case of cardiac tamponade in a previously vaccinated individual. This case highlights the importance of quick diagnosis and treatment in patients suffering from potential lethal complications of COVID-19. Reference #1: Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med. 2020;38(7):1504-1507 Reference #2: Diaz-Arocutipa C, Saucedo-Chinchay J, Imazio M. Pericarditis in patients with COVID-19: a systematic review. J Cardiovasc Med (Hagerstown). 2021 Sep 1;22(9):693-700 Reference #3: Inciardi RM, Lupi L, Zaccone G, et al. Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):819–24 DISCLOSURES: no disclosure on file for Thomas Bumbalo;no disclosure on file for Thaddeus Golden;No relevant relationships by Omar Kandah

SARS-COV-2-INDUCED COAGULOPATHY DEMONSTRATING HEMORRHAGIC CARDIAC TAMPONADE: A TIGHT SQUEEZE

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: There is a growing volume of evidence of extrapulmonary manifestations of Coronavirus disease 2019 (COVID-19), particularly within the cardiovascular and hematological systems. In this case, we describe a unique manifestation of a COVID-19 presenting with a hemorrhagic pericardial effusion and cardiac tamponade physiology with a supratherapeutic international normalized ratio (INR). CASE PRESENTATION: A 68-year-old male with coronary artery disease and atrial fibrillation on warfarin presented to the emergency department with acutely worsening shortness of breath. Upon arrival, he was hypotensive, tachypneic, and hypoxic. Physical exam findings included jugular venous distention and muffled heart sounds. A transthoracic echocardiogram demonstrated a large concentric pericardial effusion with tamponade physiology (Figure 1). Pertinent initial laboratory values included an elevated INR of 6.1, a prolonged prothrombin time of 61.2 seconds, and an elevated D-dimer level of 5.34 mg/L (Table 1). The prolonged INR was reversed with prothrombin complex concentrate (PCC). Emergent pericardiocentesis yielded 1.7L of dark-bloody appearing fluid. Pericardial fluid analysis (Table 1) demonstrated over 2.4 million red blood cells and 3,650 total nucleated cells with 94% lymphocytes. Cultures and cytology were unrevealing. Given the profound lymphocytic component, a COVID-19 nasal swab was obtained and resulted positive. Prior to contracting COVID-19, the patient's weekly INR levels were consistently at goal. DISCUSSION: The global pandemic of the COVID-19 continues to identify extrapulmonary manifestations of the disease. A rising number of publications have implicated COVID-19 with causing myocarditis, pericardial effusions, and hemorrhagic cardiac tamponade(1). Hemorrhagic cardiac effusions are typically seen with malignancy, tuberculosis, trauma, recent cardiac procedures, post-myocardial infarction, and are also seen in Coxsackie viral infections. Multiple studies implicate COVID-19 interactions with oral-vitamin K antagonists as the cause of unpredictable INR's which can lead to spontaneous bleeding2. There are fewer than 10 reported instances of hemorrhagic pericardial effusions with tamponade physiology in COVID-19 patients;however, none of the other cases presented with a super-therapeutic INR. We are also the first to demonstrate a primary lymphocytic component of the pericardial fluid suggesting viral etiology. Profound coagulopathies in COVID-19 result in an increased mortality(3). CONCLUSIONS: We propose that based on the increase in publications of case-reports describing COVID-19 viral infections and hemorrhagic pericardial effusions, that SARS-CoV-2 should be added to the list of known viral etiologies. Further, COVID-19 patients who are systemic anticoagulation with vitamin K antagonists should be monitored closely for abrupt changes in their INR. Reference #1: 1. Gupta A, Madhavan MV, Sehgal K, et al. Extrapulmonary manifestations of COVID-19. Nature Medicine. 2020;26(7):1017-1032. Reference #2: 2. Camilleri E, Van Rein N, Van Der Meer FJM, Nierman MC, Lijfering WM, Cannegieter SC. Stability of vitamin K antagonist anticoagulation after COVID-19 diagnosis. Research and Practice in Thrombosis and Haemostasis. 2021;5(7) Reference #3: 3. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. Journal of Thrombosis and Haemostasis. 2020;18(4):844-847. DISCLOSURES: No relevant relationships by Gregory Hicks No relevant relationships by Daniel Kissau No relevant relationships by Andrew Labelle No relevant relationships by Scott Mayer No relevant relationships by Dmitriy Scherbak

TUBERCULOUS TAMPONADE WITH A TWIST: A CASE OF TB AND COVID-19

SESSION TITLE: Critical Care Presentations of TB SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: We present a case of tuberculous pericarditis and cardiac tamponade due to suspected sequela of SARS-Coronavirus 19 (COVID-19) infection. It is important for clinicians to include tuberculosis (TB) in the differential diagnoses for patients presenting with presumptive viral pericarditis and tamponade. CASE PRESENTATION: A 52-year-old Hispanic man with chronic kidney disease not on hemodialysis was admitted with shortness of breath, fluid overload, hypoxemia and concern for uremic pericarditis. The patient tested positive for COVID-19 to which the symptoms were initially attributed, and he was treated with steroids, remdesevir, tocilizumab and hemodialysis. The patient incidentally had a positive QuantiFERON gold test obtained before initiating hemodialysis. On day 60 of hospitalization, the clinical exam abruptly deteriorated with stuporous mentation, hypotension, and cool skin. Bedside point of care echocardiography revealed a new large circumferential pericardial effusion with right ventricular diastolic collapse and increased respiratory variation in peak E-wave mitral inflow velocity consistent with tamponade physiology. Emergent pericardiocentesis was performed, and hemodynamic instability resolved immediately after aspiration of 750 milliliters of frank pus. Empiric antibiotics were initially given for pyogenic pericarditis. When the pericardial fluid later tested positive for acid-fast bacilli and adenosine deaminase, anti-TB therapy was started. The hospitalization was further complicated by septic shock and cardiac arrest. Though found to have a re-accumulated pericardial effusion on bedside ultrasound peri-arrest, there was no tamponade physiology (suggestive of at least a partial response to the TB treatment in the setting of overall poor underlying reserve). DISCUSSION: The coexistence of COVID-19 and tuberculous pericarditis with tamponade has been reported to date in one other case to our knowledge. COVID-19 with massive pericardial tamponade is rare and a careful diagnostic approach involving multi-modality imaging with bedside echocardiogram is invaluable in the evaluation and treatment of obstructive shock. In this case, we hypothesize that the COVID-19 infection may have led to re-activation of latent TB despite treatment of COVID-19 with corticosteroids (which are an adjunct tuberculostatic treatment in patients with tuberculous pericarditis). Tuberculous pericarditis with tamponade is a relatively uncommon manifestation of extrapulmonary TB and is a major cause of cardiovascular death and morbidity. Even with aggressive antituberculosis therapy, 30-60% of patients may need surgical pericardiectomy for constrictive pericarditis. CONCLUSIONS: This case highlights the need to consider possibility of concomitant viral and TB pericarditis in the diagnostic differential for tamponade. More histopathologic or post-mortem examinations of COVID-19 pericarditis cases are needed. Reference #1: Asif T, Kassab K, Iskander F, Alyousef T. Acute pericarditis and cardiac tamponade in a patient with COVID19: a therapeutic challenge. Eur J Case Rep Intern Med. 2020 May 6;7(6):001701. Reference #2: Barrett et al. Increase in disseminated TB during the COVID19 pandemic. Int J Tuberc Lung Dis. 2021 Feb 1;25(2):160-166. Reference #3: Wong SW, Ng J. K.X., Chia YW. Tuberculous pericarditis with tamponade diagnosed concomittantly with COVID19: a case report. Eur Heart J Case Rep. 2020 Dec 28;5(1):ytaa491. eCollection 2021 Jan. DISCLOSURES: No relevant relationships by Jaskiran Khosa No relevant relationships by Walter Klein No relevant relationships by Amy Tran No relevant relationships by Michael Ulrich

PERICARDITIS EVOLVING INTO CARDIAC TAMPONADE IN A 76-YEAR-OLD PATIENT WITH COVID-19

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Cardiac tamponade is a medical emergency that requires rapid diagnosis and intervention to prevent hemodynamic collapse. Although COVID-19 typically manifests with pulmonary symptoms, cardiac involvement is becoming better studied through increasingly frequently reported cases [1]. We present a case of COVID-19 cardiac involvement presenting as a rapidly progressive pericardial effusion turning into tamponade. This highlights the importance of a high index of suspicion for patients who develop sudden and atypical respiratory compromise with hypotension in the setting of COVID-19 infection. CASE PRESENTATION: A 76-year-old male with a history of ESRD presented with fatigue after missing hemodialysis. Laboratory investigations revealed a mild troponin elevation and positive SARS-CoV-2 PCR. Initial TTE demonstrated an EF of 60-65% with a small pericardial effusion and thickened calcified pericardium. After a few days, the patient was noted to be encephalopathic and hypotensive. Labs revealed leukocytosis, lactic acidosis as well as an elevated troponin and D-dimer. Chest CTA was significant for a large pericardial effusion with reduced size of the right ventricle, concerning for cardiac tamponade. Repeat TTE had a moderate pericardial effusion and right atrial collapse, consistent with tamponade. Given significantly elevated INR in the setting of anticoagulation, pericardiocentesis was deferred while the patient was transfused FFP. The patient subsequently suffered PEA arrest and expired despite attempted hemodynamic stabilization. DISCUSSION: Cardiac tamponade is a result of accumulating pericardial fluid culminating in decreased cardiac output and shock. Clinicians should be prompted by characteristic findings, including Beck’s triad (JVD, hypotension, and muffled heart sounds) and Kussmaul’s sign of paradoxically elevated JVP with inspiration [2]. However, the diagnosis of tamponade based solely on clinical finding is difficult and may lead to unnecessary intervention [3]. Ultimately, a diagnosis of tamponade requires both hemodynamic instability and pericardial effusion. Echocardiography, including TTE and POCUS, plays a central role in the identification of cardiac tamponade. While it is essential to note the presence of a pericardial effusion, it is important to be familiar with core echocardiographic signs of tamponade: systolic RA collapse (earliest sign), diastolic RV collapse, IVC with minimal respiratory variation, and exaggerated respiratory cycle changes in MV and TV in-flow velocities (a surrogate for pulsus paradoxus) [3]. CONCLUSIONS: Despite the classic association between COVID-19 and pulmonary manifestation, pericardial involvement has been noted in 20% of COVID-19 patients. It is therefore imperative to maintain a high index of suspicion and familiarity of characteristic echocardiogram findings of tamponade to prompt intervention and curtail cardiac hemodynamic collapse. Reference #1: Lala A, Johnson KW, Januzzi JL, et al. Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection. J Am Coll Cardiol. 2020;76(5):533-546. doi:10.1016/j.jacc.2020.06.007 Reference #2: Stashko E, Meer JM. Cardiac Tamponade. [Updated 2021 Dec 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431090/ Reference #3: Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade?. Am J Emerg Med. 2019;37(2):321-326. doi:10.1016/j.ajem.2018.11.004 DISCLOSURES: No relevant relationships by Christopher Allahverdian No relevant relationships by John Javien No relevant relationships by Vishal Patel No relevant relationships by Sarah Youkhana

Focused Ultrasound in Critical Care Outreach for acutely ill and deteriorating patients on the wards

Introduction: Focused Ultrasound in Intensive Care (FUSIC) refers to the use of ultrasound by a trained bedside clinician to guide patient management in real-time. Ultrasound is widely applied in practice and there is growing consensus that it is an essential tool for managing acutely ill patients in the intensive care unit (ICU). The Critical Care Outreach Team uses FUSIC as an additional assessment tool to guide management and decision-making plan for deteriorating patients on the wards. Objectives: To investigate whether how often information gained fromFUSICimaging had an impact on patient care and management decisions in a critical care outreach setting. Methods: A single-centre observational study at an academic tertiary referral institution. We included all patients reviewed by critical care outreach who were assessed by ultrasound during a 12-month period. Routine procedures for teaching purposes were not included. Results: Forty-six patients were assessed and supported by a combined focused lung and heart ultrasound performed at the patient bedside on the wards. In 46 patients FUSIC was instrumental in the differential diagnostic workup and in guiding the clinical management. In 32 (70%) patients FUSIC aided fluid therapy or diuresis (in case of pulmonary oedema) and helped targeting fluid balance. In three patients though to have consolidation on chest x-ray we were able to identify significant pleural effusions without needing an additional CT scan. In four patients with hypotension, an additional CT-PA was warranted due to dilated right ventricle (RV) with abnormal septal motion and decreased left ventricle (LV) size ratio (i.e. sign of right heart strain) as highly suspicious of pulmonary embolus. In two young patients with Coronavirus disease 2019 (COVID-19), using FUSIC we identified severe LV dysfunction which was subsequentially diagnosed as myocarditis and Angiotensin-converting enzyme (ACE) inhibitors therapy was commenced within 24 hours. Further diagnosis included cardiac tamponade (n = 2) requiring pericardiocentesis and pneumothorax (n =1). In all cases, the use of ultrasound helped in promptly referring patients to the specialist team (i.e. respiratory or cardiology) and to the ICU consultant. Conclusions: In our critical care outreach practice, FUSIC is considered an indispensable tool for safe and accurate management of acutely ill and deteriorating patients on the wards.

Bedside echocardiographic diagnosis of Pericardial effusion in the critically ill patient and prevention of catastrophic hemodynamic compromise

Introduction: In recent years, the use of ultrasound in critical care has revolutionized the bedside assessment of ICU patients. Though operator dependent, the advantage of repeatability and being relatively inexpensive makes it imperative for critical care physicians to stay updatedwith thismodality. The purpose of this report is to describe an incidental finding of pericardial effusion in a patent admitted with respiratory distress. Main body: A 26 years old female was admitted with shortness of breath and increase in oxygen requirements. She had a background of cerebral palsy, tracheostomized since 2009 after being operated for scoliosis and had a vagal nerve stimulator in situ. On admission, her 1st covid swab was negative. She normally required home ventilation only at night, however 2 days prior to admission, she required 24 hours of ventilator support. A large leak was noted on the ventilator and had a non-cuffed tracheostomy tube in situ, which was later changed to a cuffed one. A quick bedside FICE (Focused Intensive Care Echocardiography) revealed a large circumferential pericardial effusion with fibrin strands. There was no haemodynamic compromise on admission, however the large pericardial effusion could have been an attributing factor to her severe respiratory distress. She progressively started deteriorating hemodynamically, requiring intravenous fluids and vasopressor support. A definitive ECHO done by the cardiologist confirmed the findings of FICE. There was a rapid change in her condition post-pericardiocentesis. As per the institute protocol, a second covid swab was sent for her, which reported positive. Covid-19 RTPCR testing was not validated on pericardial fluid, hence was not undertaken. The culture of pericardial fluid revealed staphylococcus aureus, but there was a high index of suspicion of COVID and bacterial pericarditis was unlikely. Conclusion: Echocardiographic evaluation of Pericardial effusion is of paramount importance for timely and appropriate diagnosis. In view of quick bed side diagnosis with ultrasound, our patient was able to survive this life-threatening condition and treatment was initiated promptly. If left undiagnosed based on clinical presentation, it could have been catastrophic for a completely treatable cause. Brief description of ultrasound video: Pericardial effusion appears as an echo-free space between the 2 layers of pericardium. This video shows a 4-chamber echocardiographic view suggestive of a globular pericardial effusion with fibrin strands. An element of hemodynamic compromise was visible on 4-chambered view as well as para-sternal long axis view.