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.

Systemic Lupus Erythematosus and Antiphospholipid Syndrome After COVID-19 Vaccination. A Case Report.

INTRODUCTION: COVID-19 vaccines have some adverse effects, mostly mild. However, by presenting an immunological challenge to the individual, they could infrequently trigger immune-mediated diseases. CASE REPORT: We report the case of a 42-year-old woman, with no previous medical history, who received the first dose of vaccine against COVID-19 and developed inflammatory arthralgias, associated with sudden onset dyspnea and hypoxemia. Pulmonary thromboembolism was documented and the diagnosis of systemic lupus erythematosus (SLE) and secondary antiphospholipid syndrome (APS) was suspected. Autoantibodies were measured confirming this suspicion. After a few days, she presented a massive pericardial effusion with cardiac tamponade that required surgical management. She received treatment with hydroxychloroquine, corticosteroids and anticoagulation with improvement of all symptoms. DISCUSSION: There is controversy regarding the potential of COVID-19 vaccines to induce autoimmunity. Studies addressing the safety of using these vaccines have reported the occurrence of mild local and systemic reactions, most frequently in young adults. So far there are few reports of patients who have developed autoimmune or autoinflammatory diseases after getting vaccinated with any of the COVID-19 vaccines. To the best of our knowledge, to date this is one of the first cases of new-onset SLE and secondary APS after COVID-19 vaccination.

Hemorrhagic Cardiac Tamponade as a Complication of Limited Cutaneous Systemic Sclerosis.

Cardiac tamponade is an uncommon complication of systemic sclerosis (SSc) with a high mortality rate. Here, we report a case of a 58-year-old patient with limited cutaneous systemic sclerosis (lcSSc), gastroesophageal reflux disease (GERD), diabetes mellitus, pulmonary hypertension (PHTN), and COVID-19 infection, which occurred one month ago, presenting with a large hemorrhagic pericardial effusion and early cardiac tamponade. The patient had an acute onset of progressive dyspnea and anasarca. On examination, she was tachypneic, tachycardic, desaturating on room air, and hypotensive. Pitting edema up to thighs and bilateral basilar crackles were also appreciated. Labs were remarkable for negative troponin, chest X-ray with pulmonary congestion, D-dimer at 6.01, CT angiogram negative, brain natriuretic peptide level at 73 pg/mL, C-reactive protein level at 7.64 mg/dL, normal complement levels, and negative COVID-19 test results. Echocardiography showed early tamponade and a large circumferential effusion with chamber collapse. Right heart catheterization was performed finding PHTN at 54 mmHg. Pericardiocentesis drained 500 mL of the hemorrhagic effusion. Fluid analysis showed RBC at 220,000/uL, WBC at 5000/uL, protein 4.8 g/dL, lactate dehydrogenase level of 1275 U/L, and negative cytology. The patient was treated for serositis from lcSSc flare with mycophenolate mofetil and steroids, and responded very well. Hemorrhagic cardiac tamponade is a very rare phenomenon in limited scleroderma. A recent COVID-19 infection could have served as a trigger factor for our patient's lcSSc in long remission to flare up. Clinicians should maintain a high index of suspicion and a low threshold for intervention when lcSSc patients have an acute onset of cardiac compromise, especially with a history of a recent COVID-19 infection.

A Misleading Left Atrial Appendage.

Left atrial appendage collapse is a relatively unusual echocardiographic finding. Although in post-cardiac surgery patients it may be an early sign of cardiac tamponade, and pericardiocentesis should be discussed, a conservative approach may be followed in cases secondary to viral infection without confusing it with a left atrial appendage thrombus. (Level of Difficulty: Intermediate.).

Acute Cardiovascular Complications of COVID-19: A Systematic Review.

Since the pandemic in 2019, coronavirus 2019 (COVID-19) has continued to be linked with a variety of organ systems and complications. While it is generally considered a respiratory disease, its link with the heart is widely discussed in the literature. This article focuses on the acute cardiovascular complications of COVID-19 and the possible predictors of these complications. Our study included 97 articles (58 case reports, eight case series, 23 retrospective cohort studies, five prospective cohort studies, and three cross-sectional studies). Several mechanisms have been proposed to explain COVID-19-induced cardiovascular complications, with cytokine-induced inflammation and direct cardiac damage noted as the significant focus. Patients with underlying cardiovascular complications such as hypertension and diabetes were noted to be at increased risk of acute cardiovascular complications, as well as an increased risk of severe disease and death. Also, acute myocardial infarction and arrhythmias were two of the most common acute cardiovascular complications noted in our review. Other acute cardiovascular complications are myocarditis, takotsubo syndrome, acute thromboembolic events, and pericardial complications. This article provides an updated review of acute cardiovascular complications of COVID-19, its pathogenesis, and risk stratification and emphasizes the need for high suspicion in patients with underlying cardiovascular risk factors.

Acute Viral Pericarditis Complicated by Cardiac Tamponade as a Result of COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) and coronavirus disease 2019 (COVID-19) predominantly cause respiratory symptoms but cardiovascular complications from COVID-19 have been documented in the literature. Acute pericarditis has been known to be caused by COVID-19 but severe cardiac complications, such as cardiac tamponade, have rarely been reported. Early diagnosis and treatment with pericardiocentesis are imperative, as this can improve patient outcomes. A 56-year-old female presented with chest pain and recurrent episodes of presyncope. The patient tested positive for SARS-Cov-2 through a polymerase chain reaction (PCR) test. The patient was hypotensive on arrival and the initial workup with electrocardiogram was significant for sinus tachycardia with low voltage QRS complexes in the precordial and limb leads. A transthoracic echocardiogram was also done and showed a large circumferential pericardial effusion with chamber collapse of the right atrium and right ventricle during diastole indicative of tamponade physiology. The patient's clinical course was complicated by pulseless electrical activity cardiac arrest during which a pericardiocentesis was done. One hundred (100) mL of serous pericardial fluid was drained and a return of spontaneous circulation was obtained after roughly 10 minutes of cardiopulmonary resuscitation. Further infectious and noninfectious workups, including malignant and rheumatologic etiologies for acute pericarditis, were negative. The patient was subsequently treated with high-dose non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine for viral pericarditis. The patient's clinical course improved, and the patient was subsequently discharged after a prolonged hospital course to a subacute rehabilitation facility to undergo physical therapy.

First case of Arcobacter species isolated in pericardial fluid in an HIV and COVID-19 patient with worsening cardiac tamponade.

Arcobacter spp. is an emerging pathogen that is increasingly recognized as a cause of human infections. Gastrointestinal manifestations are most described in the case report literature. We present a case of the first documented case of Arcobacter spp. isolated in pericardial fluid in an immunocompromised patient with worsening cardiac tamponade that was successfully managed with an urgent pericardiocentesis and ensuing steroids, antibiotics, and a pericardial drain. The patient had a past medical history of HIV, latent syphilis, PCP pneumonia, ESRD, and hypertension, and presented with worsening dyspnea, subjective fever, myalgias, cough, pleuritic chest pain, and pericardial rub. Diagnostic workup revealed a positive COVID-19 PCR test, elevated high-sensitive cardiac troponins, elevated CRP, elevated D-dimer, and elevated creatinine. An ECG revealed diffuse ST-segment elevation, and imaging showed cardiomegaly with pulmonary vascular congestion and diffuse interstitial edema. Urgent TTE showed a large circumferential pericardial effusion with tamponade physiology present. Culture on aerobic blood agar grew Arcobacter spp. of unknown specific species, and blood cultures were also positive for Arcobacter spp. Treatment involved intravenous meropenem for five days, followed by oral ciprofloxacin, low-dose colchicine, and a tapered dose of ibuprofen. Repeat laboratory data and TTE showed complete resolution of the pericardial effusion and improved left ventricular function. This case highlights the potential for Arcobacter spp. to cause severe infections and the importance of considering it as a possible pathogen in patients with atypical presentations.

Successful intrapericardial fibrinolysis on acute recurrent purulent pericarditis with impending cardiac tamponade during pandemic situation: a rare case report

Introduction: Acute recurrent purulent pericarditis is an uncommon pericardium infection that can be life-threatening due to pus production, leading to cardiac tamponade. Case presentation: We report a 36-year-old man referring to our hospital with impending cardiac tamponade who needed urgent pericardiocentesis. The patient's complaints were worsening dyspnea and palpitations in the last two days. The patient had been hospitalized for the same complaint and had pericardiocentesis due to cardiac tamponade approximately three weeks earlier. Physical exam, ECG, and CXR suggest impending cardiac tamponade. Echocardiography indicated massive right and left pericardial effusion and right atrial collapse. The Covid-19 screening test was positive;however, RT-PCR revealed a negative result. The patient was diagnosed with recurrent acute purulent pericarditis with impending cardiac tamponade requiring urgent pericardiocentesis. After the procedure, 1.5 million units of intrapericardial fibrinolytic were administered to patients. His improved hemodynamic and clinical symptoms indicate a successful procedure. Conclusion: This case highlights the challenges of managing an acute recurrent purulent pericarditis patient due to Staphylococcus A. infection in the current pandemic era, including distinguishing it from other contagious diseases due to nonspecific dyspnea, limited therapeutic options, and the effectiveness of intrapericardial fibrinolytic in improving the overall patient conditions, and reducing the mortality rate.

Acute Pericarditis and Cardiac Tamponade in a Patient with COVID-19: A Therapeutic Challenge.

We report a case of acute viral pericarditis and cardiac tamponade in a patient with COVID-19 to highlight the associated treatment challenges, especially given the uncertainty associated with the safety of standard treatment. We also discuss complications associated with delayed diagnosis in patients who potentially may need mechanical ventilation. LEARNING POINTS: Large pericardial effusion and cardiac tamponade should be considered in patients with COVID-19 who decompensate further after intubation and mechanical ventilation.The characteristics of pericardial effusion in patients with COVID-19 are described.A successful treatment approach for acute pericarditis in a patient with COVID-19 in light of differing opinions over the safety of NSAID use is described.

Inflammatory process of the COVID-19 fulminant myocarditis in the multimodality imaging: a case report.

Background: Cardiac manifest of COVID-19 infection was widely reported. The pathophysiology is thought the combination of direct damage caused by viruses and myocardial inflammation caused by immune responses. We tracked the inflammatory process of fulminant myocarditis associated with COVID-19 infection using multi-modality imaging. Case Summary: A 49-year-old male with COVID-19 went into cardiac arrest from severe left ventricular dysfunction and cardiac tamponade. He was treated with steroids, remdesivir, and tocilizumab but failed to maintain circulation. He recovered with pericardiocentesis and veno-arterial extracorporeal membrane oxygenation in addition to the immune suppression treatment. In this case, a series of chest computed tomography (CT) was performed on Days 4, 7, and 18 and cardiac magnetic resonance (MR) on Days 21, 53, and 145. Discussion: Analysis of the inflammatory findings on CT in this case showed that intense inflammation around the pericardial space was observed at an early stage of the disease. Although inflammatory findings in the pericardial space and chemical markers had improved according to non-magnetic resonance imaging (MRI) tests, the MRI revealed a notable long inflammatory period more than 50 days.

Histopathological findings of pericarditis in a patient with multisystem inflammatory syndrome in children associated with COVID-19: A case report.

Multisystem inflammatory syndrome in children (MIS-C), which is associated with the novel coronavirus disease 2019 (COVID-19), has been described as an inflammatory complication of exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It carries a risk of serious and lethal complications, including cardiogenic shock. Here, we report the pathological findings of the pericardium in a 10-year-old child with MIS-C, who developed pericarditis-induced cardiac tamponade. In the patient's pericardium, the numbers of infiltrating CD68+ macrophages; CD3+ , CD4+ , and CD8+ T cells; and myeloperoxidase+ granulocytes were increased, although the number of CD20+ B cells was not. These findings provide a clue to understanding the pathophysiology of MIS-C.

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.

Spotting the Needle Amongst the Haystack - When Asthma Isn't Asthma

Introduction/Background: Eosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss Syndrome, is a rare, small to medium vessel ANCA associated vasculitis. Hallmarks of EGPA include asthma, chronic rhinosinusitis, and peripheral neuropathy. EGPA is characterized by a prodrome of asthma and allergic rhinitis, followed by peripheral blood hyper-eosinophilia and accumulation of extravascular eosinophils, and finally systemic vasculitis. Extrapulmonary involvement is common, sometimes with fatal outcomes. The onset of EPGA is typically between 25-50 years;however, EGPA also occurs during childhood and has a significant morbidity and mortality. Description/Method: Our patient presented to the emergency department with a 2-week history of lethargy, wheeze and left sided neck swelling. After testing COVID-19 positive eight months prior to this, she developed wheezy episodes and was subsequently diagnosed with asthma which was managed with bronchodilators as required. She was reviewed by an allergist who confirmed a dust mite allergy and prescribed Montelukast. She remained well during the summer months however during winter she had 3 distinctive episodes of wheeze and cough which were managed by antibiotics and prednisolone. In the emergency department, an echocardiogram was performed which showed a cardiac tamponade. She was transferred to CICU where she had a pericardial drain inserted. The fluid was abundant with inflammatory cells. Multiple investigations were performed as follows: Hb: 135g/L, wbc: 20.30 x 10 9/L, Eosinophils: 12.77 x 10 9/L, CRP: 51 mg/L, ESR: 75 mm/hr, LDH: 1188 IU/L, IgE: 8000 UI/ml, ANA, ANCA: negative. CT chest showed mediastinal lymphadenopathy and patchy bilateral infiltrate and cardiac MRI showed myopericarditis and LV fibrosis. BMA showed no malignant cells and sinusitis was confirmed by CT. On examination, she was underweight. Her nasal mucosa looked inflamed. Otherwise systemic examination was unremarkable. In the context of poor ejection fraction (20%) with LV fibrosis, urgent MDT was arranged and concluded that our working diagnosis was EGPA. The decision was made to start IV methylprednisolone 10mg/kg/day for 3 days and Ivermectin. That night our patient had a VF arrest which required a single shock conversion 4J/kg. There was 7-minute downtime. Treatment was escalated to include cyclophosphamide, rituximab and plasmapheresis. The patient made a remarkable recovery, extubated and transferred to a normal ward. Her eosinophils count and inflammatory markers improved dramatically following treatment. However, she developed severe neuropathic left leg pain and NCS confirmed peripheral neuropathy Discussion/Results: EGPA is a very rare disease and diagnosis can be challenging especially with the absence of histopathology diagnosis. Early empirical treatment especially in a very ill child in intensive care unit can save lives and divert the progress of the disease. This patient has fulfilled the American College of Rheumatology criteria to diagnose EGPA including asthma, eosinophil count > 10% of upper normal, peripheral neuropathy, pulmonary infiltrates on CT thorax and paranasal sinuses abnormalities. Cardiac biopsy of the fibrotic mass may be a useful tool for diagnosis;however, this invasive procedure may expose this patient with high risk of fatal arrhythmias. Since other causes of eosinophilia were ruled out including parasitic infections, lymphoproliferative disorders, and rare primary immunodeficiency syndromes (hyper-IgE syndrome due to STAT3 or DOCK8 deficiency and Omenn syndrome) and the patient responded well to treatment, the diagnosis of EGPA was supported. Key learning points/Conclusion: Asthma not responding to bronchodilator could be another diagnosis Eosinophilia should be interpreted with caution. Defer the need for histopathology diagnosis in critically ill children Cardiac involvement is a life-threatening marker Early diagnosis prevents life threatening complications.

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.

Hemorrhagic Cardiac Tamponade-An Unusual Threat in the COVID-19 Recovery Phase.

Cardiac tamponade is a rare presentation in patients with COVID-19, which may be induced by the associated exacerbated inflammatory response. The onset of cardiac tamponade may be concomitant with the acute phase of the disease or may develop subsequently as a new health condition secondary to the disease. We report four cases of cardiac tamponade that occurred late after the acute phase of the disease. One of them may be considered a post-acute complication of the disease, and three of them may be classified as a new health condition induced by COVID-19. Only two cases had a history of severe respiratory distress due to COVID-19. In all four cases, pericardiocentesis was imposed, and surprisingly, in every case, hemorrhagic fluid was evacuated. In this case, series, immune-mediated etiology is supported by histopathological results, where the main identified feature was fibrous pericarditis with inflammatory infiltrate. Only one patient included in this report died, and three of them were discharged after anti-inflammatory treatment was initiated.

S P O N Ta N Eous R E S O Lut I O N O F Large Pericardial Effusion after Cardiopulmonary Resuscitation in a Chronic Kidney Disease Patient on Maintenance Haemodialysis

BACKGROUND: Here we discuss a chronic kidney disease (CKD) patient with large pericardial effusion who arrested secondary to tamponade and had an unintentional pericardial decompression secondary to cardiopulmonary resuscitation (CPR) that subsequently saved his life. AIM OF THE STUDY: To bring to light management difficulties in chronic kidney disease patients undergoing maintenance hemodialysis with large pericardial effusion METHODS: 67-year-old male a case of CKD on maintenance hemodialysis (for last two years) but inadequately dialyzed over last two months after recent Covid pneumonia was detected to have large pericardial effusion on echocardiography. He was planned for intensive heparin-free dialysis in view of absence of frank clinical and echocardiographic findings of tamponade with close surveillance for pericardial effusion. 60 minutes into hemodialysis patient developed dyspnea hypotension and cardiac arrest. Return of spontaneous circulation was achieved after three cycles of cardiopulmonary resuscitation. Echocardiography (echo) guided pericardiocentesis was planned based on clinical suspicion of tamponade. But echocardiography revealed only mild pericardial effusion. Chest X-ray showed new left pleural effusion. Pleurocentesis revealed hemorrhagic fluid. Subsequently done CT thorax showed multiple rib fractures. Patient was discharged on day eleven in stable condition with repeat chest X ray and echocardiography showing no further collection. RESULT(S): Though cardiac tamponade is largely a clinical diagnosis, various other features like echocardiography aid in its diagnosis. Diagnosis of tamponade in CKD patient with pericardial effusion is difficult because of several reasons. All classical clinical features of tamponade like hypotension or elevated systemic pressures may not be manifested all the time in cases of tamponade. Our patient developed clinical signs of tamponade 60 minutes into dialysis session indicating that precipitation of tamponade was likely due to reduction in preload due to ultrafiltration (UF) during hemodialysis. Though, daily dialysis is the initial preferred treatment of choice for uremic pericardial effusions in CKD patients without clinical or echocardiographic signs of tamponade, there are case reports which support early pericardiocentesis as treatment of choice in all large pericardial effusions in CKD patients on maintenance hemodialysis (MHD). In our case of large pericardial effusion, due to absence of frank clinical/ echocardiographic evidence of tamponade, we were prompted to go for aggressive dialysis treatment plan, but had tamponade during dialysis. CPR can cause inadvertent injury to surrounding structures, ribs, abdominal organs, and vascular injury. In our case, CPR-associated injury leads to unintentional pericardial decompression probably due to rib injury or due to high force generated during CPR coupled with high pericardial pressures which overcame the tensile strength of pericardium resulting in pericardial decompression. Findings of fractured ribs on CT scan post-resuscitation in our case supports that high force and pressure were generated during CPR. CONCLUSION(S): This case report supports early pericardiocentesis as treatment of choice for large pericardial effusion in CKD patients on MHD. Also, care should be taken while dialyzing these patient as rapid UF can precipitate tamponade.

Traditional Cardiopulmonary Resuscitation In Cardiac Arrest For Patients On Venovenous Extracorporeal Membrane Oxygenation

Introduction: Mortality for patients on VV-ECMO remains high despite increased use during the COVID-19 pandemic. Unlike VA-ECMO which provides life support for cardiac failure and can be used as a bridge to definitive therapy during cardiac arrest (e-CPR), patients who arrest while on VV-ECMO currently may undergo traditional cardiopulmonary resuscitation (CPR). This poses many challenges such as potential cannula position disruption of the VV-ECMO system during compressions and it is unclear if patients on VV-ECMO will benefit from being offered traditional CPR. Hypothesis: Traditional CPR is effective in patients who arrest while on VV-ECMO. Method(s): A retrospective chart review of inpatient cardiac arrest data from a high-volume ECMO center was performed. Patients who arrested while on VV-ECMO were included. Data including demographics, etiology of arrest, return of spontaneous circulation (ROSC) and survival to discharge were reviewed. Survival data was compared with the ECLS International Summary of Statistics. Result(s): We identified 19 patients on VV-ECMO who underwent CPR for cardiac arrest between September 2012 and November 2021. The average age of the patients was 42.7 years and 89.5% (n=17) were men. Seven of the nineteen total patients (36.8%) were being treated for ARDS from COVID-19 pneumonia. The arrest occurred on average 35.6 days into hospitalization (range: 1-132 days). The initial rhythm was pulseless electrical activity in 13 patients (68.4%), and the etiologies of arrest included hypoxemia (n=10, 52.6%), ECMO machine failure or during oxygenator exchange (n=3, 15.8%), pneumothorax (n=2, 10.5%), and cardiac tamponade (n=1, 5.3%). ROSC occurred in all 19 patients (100%), however only 4 patients (21.1%) survived to discharge with good neurologic recovery. Survival to discharge for all-comers on VV-ECMO is 66%. Conclusion(s): While there is limited evidence for the effectiveness of traditional CPR for patients on VV-ECMO, in this sample, ROSC was universal and one-fifth of patients survived to discharge. Future studies should continue to study the utility of CPR on VV-ECMO and how to optimize technique to improve outcomes for these critically-ill patients.

Subacute Cardiac Tamponade With Massive Pericardial Effusion.

Subacute cardiac tamponade is a diagnostic challenge for clinicians because the symptoms would be non-specific upon presentation. The onset of cardiac tamponade may vary depending on the rate of accumulation and compensatory mechanism of the fibroelastic pericardial sac. In the case of subacute tamponade with effusion without cardiac arrest, it is usually challenging for the clinician to make the decision for urgent drainage. Usually, cardiac tamponade is treated as a medical emergency, and it occurs when fluid accumulated in the pericardial sac compresses the heart causing haemodynamic compromise and cardiac arrest. In our case, a 40-year-old man presented with a seven-day history of significant shortness of breath. He presented to the emergency department and the chest X-ray showed a large cardiac silhouette, which suggested a large pericardial effusion. ECG revealed minor changes in the heights of QRS complexes. Point-of-care echocardiography showed a large pericardial effusion, and he was immediately admitted to the cardiac unit. Urgent departmental echocardiography confirmed massive pericardial effusion with features of subacute tamponade. The patient was sent to the cardiac catheterisation lab and a total of approximately 4.2 litres of pericardial effusion was drained, while he was closely monitored for the risk of rapid physiologic decompensation after drainage. Pericardial fluid culture did not show any evidence of microorganism growth. The connective tissue disease screen was negative. CT scan did not show any stigmata of occult malignancy or features of infection. The coronavirus disease 2019 (COVID-19) polymerase chain reaction test was negative. He had rapid symptomatic improvement after the effusion was drained and recovery was uneventful. He was discharged from the hospital with a follow-up plan. We concluded that it was a case of subacute cardiac tamponade due to a massive pericardial effusion of idiopathic or subclinical viral causes. Clinical presentation of subacute cardiac tamponade could be easily missed, and a detailed assessment of the effusion with echocardiography was very helpful in making decisions for the management.

Case Report: Recurrent pericardial tamponade in a child with COVID-19.

Background: Pericarditis is rare in Coronavirus disease 2019 (Covid-19) infection and only a few cases were reported in children. Case presentation: We present the case of a 15-year-old boy with symptoms of high fever and worsening chest pain during COVID-19 infection. Chest computer tomography (CT) and echocardiography confirmed pericardial tamponade requiring urgent drainage. Despite antiviral drug treatment, after 18 days severe attack developed requiring repeated pericardiocentesis. High dose ibuprofen, colchicin and the interleukin-1 antagonist, anakinra were given. Clinical symptoms and laboratory parameters improved after seven days of treatment. Autoinflammatory diseases were also suspected in the background the severe pericarditis, but genetic analysis ruled out any mutations. Conclusion: Pericarditis associated with COVID-19 infection may present in the acute phase or later as MIS-C. Though pericardial tamponade related to ongoing Covid-19 infection is rare in children, even biological treatment with interleukin-1 antagonist may be needed to control the inflammation.

Subacute Cardiac Tamponade in a COVID-19 Patient Despite Negative Testing.

COVID-19 infection has been documented to cause a wide range of symptoms including cardiac complications. We present a case of subacute cardiac tamponade in a patient infected with COVID-19 in the absence of respiratory symptoms; we also review the current literature on this rare sequela. Our patient is a 67-year-old man who presented to the hospital due to intermittent chest pain for three weeks. COVID-19 polymerase chain reaction (PCR) testing was negative two times. He had an outpatient echocardiogram that showed a moderate pericardial effusion about a week prior to the hospital presentation. On admission, a repeat echocardiogram showed a large pericardial effusion with tamponade physiology. Pericardiocentesis did not reveal a clear etiology of the hemorrhagic effusion but four days later, the patient was found to be positive for COVID-19 infection without any clear respiratory illness. Given the absence of other etiology and negative workup, cardiac tamponade was attributed to pericardial inflammation from this virus and our patient improved with colchicine and steroids. We, therefore, advise providers to consider COVID-19 as a cause of hemorrhagic, cryptogenic cardiac tamponade despite negative COVID-19 testing. We also review 42 additional reported cases of cardiac tamponade in patients infected with COVID-19. COVID-19 can cause cardiac tamponade even in the absence of pulmonary disease. This case and literature review highlight tamponade as a rare complication of COVID-19 and should be considered in the differential of any acute deterioration in this patient population.